A young Bristol student who collapsed and died late at night at a city centre gym would probably not have been saved even if the gym had been fully staffed and paramedics reached him more quickly, a coroner has ruled.
Coroner Dr Peter Harrowing recorded a conclusion that Henry Best died of natural causes after he collapsed suffering a cardiac arrest at the Pure Gym in the Harbourside in Bristol on the evening of January 10 this year. Dr Harrowing said there was no need for a narrative verdict at the end of an inquest that lasted for a day and a half.
And Dr Harrowing also said there was no need for him to make recommendations to prevent future deaths, after hearing that Pure Gym had ‘learned lessons’ and made changes to the way their gyms operate late in the evening, following a report into the tragedy by Bristol City Council’s health and safety officers.
Read more: Family's heartbreak and concern as young man dies at Bristol PureGym
Henry Best was teetotal, and a fit, healthy and active music student who helped run swimming lessons for primary school children and went to the gym regularly. The inquest heard that he was a popular young man and talented musician who cared for everyone around him.
The inquest at Avon Coroner’s Court heard how the 21-year-old student collapsed from a pre-existing but previously undiagnosed heart condition around an hour into a workout at the gym with his girlfriend Holly Jones. They had gone to the gym together at around 10.30pm that evening and Mr Best collapsed in a room on the fourth floor of the building at around 11.30pm.
The family of Mr Best were represented in the inquest, as was Pure Gym, after concerns were raised by the family about staffing, signage and the ability for paramedics called to the scene to reach Mr Best. The inquest heard paramedics were in an ambulance nearby and after being dispatched at 11.31pm, they arrived outside the front of the gym at 11.35pm, but took another six minutes to reach him, after spending a minute or so retrieving equipment from the back of the ambulance. The distressing scenes inside the gym were explained in a series of statements from other gym users who were there and tried to help, and from the paramedics themselves.
The inquest heard that Holly Jones dialled 999 immediately and, under the instruction of the emergency call handlers, administered CPR to Henry for ten minutes before the paramedics took over. Two other gym users in the area at the time came to help, and went off to try to find a member of staff.
At the time, the only member of staff on the premises was a first-aid trained cleaner. Pure Gym is open at other times when it is completely unstaffed and, in those circumstances, there would have been signs up and tannoy announcements informing people that there was an emergency system. The gym, which often operates unstaffed through the night, has an emergency button in most rooms and corridors, signs with a phone number to connect to a central operations room and there was a defibrillator on the same floor as the room where Henry collapsed. On the evening Henry collapsed, tannoy messages explaining emergency procedures were playing every 15 minutes.
At the time, the presence of the cleaner, who was first aid trained, meant the gym was designated as ‘staffed’. The two men who came to help went looking for a staff member at the gym but did not find anyone.
The inquest heard that when paramedics arrived, they could not initially get into the building and had to phone up the emergency number on the door to connect to the control centre to gain access, and once inside, walked around calling out trying to find Mr Best, even phoning back to ask if they were in the right place.
Within minutes, one gym user did come down to meet them on the ground floor and take them to Mr Best, and they arrived at the scene in that room at 11.41pm. The inquest heard that CCTV evidence revealed the cleaner had gone into a cleaning cupboard at 11.19pm, and had told council health and safety investigators that he had been wearing headphones. CCTV footage viewed by police showed that one gym member, who was looking for a member of staff to help Mr Best, knocked on the cleaning cupboard door at 11.38pm, but the cleaner had not responded. CCTV showed the cleaner left the cleaning cupboard at 11.46pm and continued working - completely unaware of the medical emergency on the fourth floor.
Mr Falls from Bristol City Council was in the witness box, and questioned over his report. In the course of this questioning, from both Dr Harrowing and Ms Randel, he said: "Basically he was unaware of anything that was happening. He did say he had headphones on at the time".
"PC Driscoll watched CCTV and from his notes, the cleaner entered the cupboard at 23:19 and at 23:46 the cleaner leaves the cupboard. One of the males knocked on the cupboard door but didn't get a response. I'm not sure if that was the cupboard he was in or whether he was listening to music."
Dr Harrowing said that, on the balance of probabilities, the lack of a member of staff present in the room with Mr Best did not change the outcome for Mr Best, since at the point the gym user knocked on that cleaning cupboard door, the paramedics were already on the scene. He said the gym’s staffing policy late at night was not ‘like a lifeguard in a fixed position’, and that the person there working was primarily as a cleaner.
Rachel Lyne, for Pure Gym, said that the report from Bristol City Council’s health and safety department did set out 'a level of confusion' that existed at the time around whether the gym was staffed, and made recommendations around what the status of a ‘manned’ or ‘unmanned’ gym were. She said Pure Gym had learned lessons and made changes to the way their gyms operate at night and said they no longer classified a gym as being ‘staffed’ if there was just a cleaner on site. In that circumstance, the procedures for the gym being ‘unstaffed’ were activated, including the tannoy announcements, signs and messages on screens advising users that the gym was unstaffed.
In making his conclusion, Avon assistant coroner Dr Harrowing said he ‘made no criticism’ of the men in the gym who did not activate the emergency button or call the gym’s emergency number, or find the defibrillator, but instead searched the building looking for a member of staff. “I have presided over enough inquests to know that members of the public may not always react in an ideal manner in such stressful circumstances and I make no criticism of these individuals who were there with Holly,” he said.
On the need for a coroner’s recommendation to prevent further deaths, Dr Harrowing said: “I agree there were some issues relating to staffing but on the balance of probabilities, it wasn’t causative or contributory to the death of Mr Best. Changes have been made I do not consider it necessary to make recommendations. I welcome the actions taken by Pure Gym in this respect,” he added.
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