'We feel let down' - Natalie's parents (From Gazette Series)

'We feel let down' - Natalie's parents

AN INQUEST into the death of Charfield teenager Natalie Dibden has found that the death was accidental.

A jury of five men and six women heard two days of evidence before taking just over an hour to decide upon their verdict.

The inquest started by establishing that, although Natalie, of Orchard Close, did not go out often, she had been taken to Bristol Royal Infirmary in January, 2003, after drinking too much.

Following that the inquest heard about events surrounding the night out that Natalie and her friends had been having on Saturday, November 8, last year.

Darren Donny, 17, a co-worker of Natalie, at Michaelwood Services, who had just started dating her, said he had met her outside the Warehouse at around 11.45pm after she was dropped off by her mother.

Neither Natalie, Mr Donny nor any of their other friends were asked to produce any identification on entering the club.

Mr Donny and Warehouse barman Liam Sinclair described how Natalie drank one pint of lager and 12 shooters - cocktails of spirits and other strong liquors served in a shot glass - in the two hours she was in the club.

Mr Sinclair said he had joked with Natalie that she should "slow down", but he did not refuse to serve her or Mr Donny and added that he thought it was the responsibility of the doormen to check the age of customers.

The inquest was told that Natalie - who was visiting the Warehouse for the first time - was escorted outside around 1.45pm after she fell off her chair and had trouble standing up.

Proceedings were then interrupted after a private investigator hired by Natalie's maternal grandmother attempted to ask Mr Sinclair a question.

However, Gloucester coroner Alan Crickmore gave the investigator short shrift as he had no right of audience and the family were already "properly represented".

On resuming, another Warehouse employee, Timothy Coleman, told the inquest that by 2.15am Natalie was lying in Parsonage Street, which prompted bystanders to call for an ambulance.

Shortly afterwards Natalie was loaded into an ambulance that set off for Gloucester Royal Hospital followed by her mother in her car.

Natalie's mother, Sarah Dibden, frequently had to pause to compose herself as she then told the inquest how she saw her daughter fall from the ambulance as it travelled northwards on the M5.

She said: "I realised the back door was open and I could see Natalie hanging onto the door.

"I started to pull over. I saw her drop off the door and the door close. I did not see anyone behind Natalie at the time.

"I pulled over and got out to get to Natalie. I shouted 'Oh my God, no' and I was praying. I got on my knees and was calling her name. She wasn't responding."

Later in the first day of evidence, ambulancemen Alan Twinning and Peter Fuller gave their accounts of how Natalie came to leave the vehicle.

Mr Twinning, who was driving the ambulance and was in a separate compartment, said he only realised something was amiss when, via his internal rear view mirror, he saw her standing up facing the door.

Seconds later, with the vehicle travelling at 70mph, he heard Mr Fuller shouting "She's gone, she's gone".

Mr Fuller explained that he had undone one of the two safety straps that prevent patients from falling off the stretcher as he thought it would make Natalie more comfortable.

She appeared to be close to being sick and had repeatedly stated that she needed to go to the toilet.

However, with the chest strap undone, Mr Fuller stated that Natalie suddenly undid the leg strap herself and swung a leg off the stretcher.

Mr Fuller said: "I said 'Natalie, you can't sit like that. You're not safe there.

"I will compromise. I will put the stretcher up for you and you can sit back there."

But, as Mr Fuller adjusted the head of the stretcher, which was at the opposite end of the compartment to the door, he saw Natalie make a move for the door "at speed".

He added: "I reached out to grab her arm but the latex glove I was wearing just tore away and I couldn't maintain my grip.

"In the same movement she managed to open the catch on the back door and jump out. She was gone."

Mr Fuller went on to say that at no point in his training as an ambulance technician had the issue of a patient trying to leave a moving vehicle cropped up.

Both ambulancemen told the inquest that it was not their policy to fully lock the rear door because of safety fears in case of a road traffic accident or an attack on a crew member by a patient.

The jury heard that Mr Twinning, Mr Fuller and Mrs Dibden attended to Natalie on the carriageway. She was unconscious and was bleeding from her ears, nose and mouth.

Natalie was eventually placed back into the ambulance and was taken to Gloucestershire Royal Hospital with her mother alongside her.

Day two of the inquest opened with two police officers giving their accounts of events in the hospital after the Natalie was admitted.

PC James Gibson described how Mr Fuller "looked ghostly white" and was "physically shaking" after he arrived at the hospital.

He added that Mr Fuller had a washing-up bowl between his feet which he looked ready to be sick into.

Further witnesses then gave details of the policies and training programmes of the Gloucestershire Ambulance Trust to explain that Mr Fuller and Mr Twinning had acted in accordance with best practice.

West Midlands Ambulance Service training manager James Carswell explained that the two stretcher straps should be fastened for basic safety, but staff had no direct authority to insist a patient had them on.

He added that as Natalie had been retching, it was the priority of Mr Fuller to adjust the back rest before fastening the strap that Natalie had undone.

The inquest then heard from Gloucestershire Ambulance Trust training manager Ian Bateman, who confirmed that staff were not trained in the matter of a patient attempting to leave the vehicle unexpectedly.

He said: "It is not something that has been discussed as it is not something that has happened."

This backed up the evidence of Mr Twinning, who said that in his 28 years in the service he only seen two incidents of patients exiting the vehicle.

Neither was at speed and they were both more than 25 years ago.

Further expert witnesses stated that the ambulance had no defects other than that the warning light that informs the driver that a door was open had never been connected.

It was also explained that the door could only have been opened by using the handle.

Concluding the evidence, Mr Crickmore said that Natalie died at 1.25pm on Sunday, November 9, after her life support machine was switched off.

He said a home office pathologist had confirmed the cause of death as a subdural haematoma and brain swelling caused by a blunt impact, consistent with ejection from a moving vehicle.

Directing the jury, Mr Crickmore said that if they saw fit they could reach a verdict of accidental death, but could also choose a narrative verdict.

This would include mention of a system failure in the fact that the doors were unlocked, the safety belts were undone or there was no relevant risk assessment in the training of crews.

The jury retired for an hour and a quarter and on returning gave a unanimous verdict of accidental death and also confirmed the cause of death as that previously given by the pathologist.

Mr Crickmore added that the Warehouse nightclub would be sent a rule 43 letter for failing to prevent under age drinking on their premises.

He ended proceedings by offering his condolences to Natalie's mother, father, two brothers and the rest of her family.

After the inquest parents Steve and Sarah Dibden said after the hearing they felt "very greatly let down" by establishments in which they had put their trust.

Mrs Dibden, who was following the ambulance in her car and she saw her daughter fall into the road, said she regretted not travelling with Natalie but thought the ambulance crew had not done their jobs properly.

She said: "I know I didn't go with her in the ambulance and I have to live with that but I trusted those people to look after her and care for her and they did not do that."

Mr Dibden stated: "We feel let down by the conduct of people at the Warehouse in Dursley as it was stated on a number of occasions that there were quite a few opportunities for the staff to refuse my daughter drinks.

"The verdict of accidental death is proof that that was what happened but we feel let down by what happened in the ambulance.

"There is a simple solution to stop that sort of accident happening again and we would like to think that lessons have been learned."

Mr Dibden was alluding to the fact that it is the policy of the Gloucestershire Ambulance Trust crews not to lock the doors of their vehicles while they are in transit.

The inquest heard that this policy allowed Natalie to open the back door of the ambulance and fall out, although in returning a verdict of accidental death the jury ruled the policy was not flawed.

Keith Scott, acting chief executive of the Gloucestershire Ambulance Trust, said: "The death of Natalie Dibden is a truly distressing incident. The Gloucestershire Ambulance Trust would like to stress once again its heart-felt sorrow to the family.

However, he added: "We are not looking to modify the locking mechanisms. There are very valid reasons for not doing so."

Terry Coles, owner of the Warehouse, the nightclub in Dursley heavily criticised by Gloucester coroner Alan Crickmore for allowing Natalie Dibden to go binge drinking, declined to comment

Mr Crickmore had said: "There is no doubt that the ability of young people to attend licensed premises to binge drink is a matter of concern.

"Had Natalie not been binge drinking in the Warehouse, the circumstances we have heard about were unlikely to have occurred."

A toxicological analysis of blood taken from Natalie after the accident showed that her blood alcohol content was 230mg per 100ml - almost three times the legal limit for driving.

Calculations made from that reading estimated the level would have been between 266mg and 305mg when she left the Warehouse.