HER MAJESTY’S SENIOR CORONER FOR THE COUNTY OF DORSET CORONER: SHERIFF S. PAYNE ASSISTANT Brendan J. Allen CORONERS: Richard T. Middleton Stephen J. Nicholls Cannons Law Practice Aviation Lawyers 14 Somerset Place GLASGOW G3 7JT 16" February, 2015 Our Ref: SSP/LJ/1004/12(W) Your Ref: FC/WestR0101 Dear Mr Cannon, RE: Richard Mark WESTGATE Deceased | am pleased to enclose copies of letters | have sent to BA and the CAA together with the Report to Prevent Future Deaths. | will of course advise you of the outcome. ‘Once again | would like to thank you for the manner in which you have put together your dossier and submissions and also for supplying the memory sticks and three copies of all relevant documents. Yours sincerely, Sheriff $ Payne — HM Senior Coroner ‘THE CORONER'S COURT STAFFORD ROAD BOURNEMOUTH DORSET BHI IPA Telephone: 01202 310049 Fax: 01202 780423 _Britdoe: DX 156942 Bournemouth 3 email: coroner@bournemouth.gov.uk.Chief Operating Officer Civil Aviation Authority CAA House 45-59 Kingsway LONDON WC2B 6TE 16" February, 2015 Our Ref: SSP/L3/1004/12(W) Dear Sir, Re: Richard Mark WESTGATE Deceased Tenclose: 1. A Regulation 28 Report to Prevent Future Deaths. 2. A Schedule of the documents supplied to me by Frank Cannon an Aviation Lawyer acting on behalf of the family of Richard Mark Westgate. 3. AUSB memory stick containing the documents on the schedule. I shall be holding an Inquest in due course into the circumstances of Mr Westgate’s death and am treating your organization as an interested person. This entitles you to legal representation at the Inquest. I shall be holding a Pre-Inquest Review at this Court at 11.00 a.m. on Wednesday the 25” March 2015. Please let me have details of who will be representing you so that I may forward an Agenda to them prior to the hearing. Please note that not all of the documents are relevant to or will be used at the Inquest hearing. Yours faithfully, SS Payne HM Coroner EncsChief Executive British Airways Waterside PO Box 365 Harmondsworth UB7 OCB 16" February, 2015 Our Ref: SSP/LI/1004/12(W) Dear Sit, Re: Richard Mark WESTGATE Deceased Tenclose: 1. A Regulation 28 Report to Prevent Future Deaths. 2. A Schedule of the documents supplied to me by Frank Cannon an Aviation Lawyer acting on behalf of the family of Richard Mark Westgate. 3. AUSB memory stick containing the documents on the schedule. T shall be holding an Inquest in due course into the circumstances of Mr Westgate’s death and am treating your organization as an interested person. This entitles you to legal representation at the Inquest. I shall be holding a Pre-Inquest Review at this Court at 11.00 a.m. on Wednesday the 25" March 2015. Please let me have details of who will be representing you so that I may forward an Agenda to them prior to the hearing. Please note that not all of the documents are relevant to or will be used at the Inquest hearing. Yours faithfully, SS Payne HM Coroner EncsSheriff Stanhope Payne, Senior Coroner for The County of Dorset REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2) | REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Chief Executive — British Airways 2. Chief Operating Officer — Civil Aviation Authority CORONER | | am Sheriff Stanhope Payne, senior coroner, for the coroner area of Dorset 2 | CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | 3 | INVESTIGATION | On 27 December 2012 | commenced an investigation into the death of RICHARD MARK WESTGATE, aged 43.. The investigation has not yet concluded and the inquest has not yet been heard. CIRCUMSTANCES OF THE DEATH On 12" December 2012 Richard Mark Westgate was found deceased in his room at the Bastion Hotel in Bussum, Netherlands. His body was repatriated to | Dorset. He was a British Airways pilot who had been on medical leave since September 2011 suffering cognitive dysfunction, ataxia & other deficits. Post mortem examinations gave causes of death of either Pentobarbital toxicity or | lymphocytic myocarditis, individually or in combination. Testing of samples taken both prior to and after death disclosed symptoms consistent with exposure to organo-phosphate compounds in aircraft cabin air. Such exposure can cause lymphocytic myocarditis. ford Roud, Bournemouth, Dorset, BHL IPA ‘Tel 01202 484910 | Fax 01202 780823CORONE! CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you, The MATTERS OF CONCERN are as follows. — (1) That organo-phosphate compounds are present in aircraft cabin air. (2) That the occupants of aircraft cabins are exposed to organo-phosphate ‘compounds with consequential damage to their health (3) That impairment to the health of those controlling aircraft may lead to the death of occupants. (4) There is no real time monitoring to detect such compounds in cabin air. | (5) That no account is taken of genetic variation in the human species, such as ‘would render individuals tolerant or intolerant of the exposure. ‘ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and | believe your organisation has the power to take such action YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 13” April 2015. |, the coroner, may extend the period Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION Ihave sent a copy of my report to the Chief Coroner and to the following Interested Persons, Frank Cannon of Cannons Law Practice acting on behalf of | the family of the deceased | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of | your response by the Chief Coroner. 16" February 2015 _ = Sheriff Stanhope Payne --= Senior Coroner for Dorset > eA SD flord Road, Bournemouth, Dorset, BHI IPA ‘Tet 01202484910 | Fax 01202 780423,