It took six months for ambulances to have locks fitted
CORRESPONDENCE released by the HSE shows that it took more than six months after the death of paramedic Simon Sexton for locks to be fitted to all 188 ambulances with dangerous side doors.
And emails reveal that at one point it was feared the fleet would have to be taken off the road due to delays in fixing the doors.
Mr Sexton died on June 3, 2010, after his fall from a moving ambulance.
But it took until mid-December that year for affected ambulances to be fitted with motion-activated locks.
The HSE has refused to release correspondence within the management of the National Ambulance Service relating to the tragic accident.
An official said "the circumstances surrounding the death of Mr Simon Sexton are still the subject of ongoing investigations, both legal and otherwise".
However, the organisation did release details of the steps it took to prevent similar accidents in the future.
An interim standard operating procedure was drawn up and it was decided that a Safety Action Notice should be issued to all crews and be posted on all ambulance side doors instructing crews not to open the doors unless in an emergency.
It was also ordered that tape be placed in an x-pattern across the handles to prevent their use and a picture of how this was to be carried out was sent to ambulance stations.
Heavily redacted email correspondence between the HSE and companies hired to install the motion-activated locks shows the delays in getting the doors modified.
In one email on September 9, 2010, a HSE official wrote: "Just following up on the modifications to the side doors.
"I am sure you appreciate that I am concerned that we get to a point of agreeing the costing and work schedule to get this project sorted.
"I have to update the Health and Safety Authority on our progress and would welcome something asap."
An email four days later warns of "more haste less speed" in the procurement process and notes that parts of the modifications take five days to be delivered.
An email on October 22 noted that the HSE had imposed a "deadline of December" for completion.
However, almost two weeks later on November 3, a HSE official wrote about concerns about obtaining parts for the modifications.
And they added: "Given the H&S Authority have informed me that they are considering an enforcement order in relation to this issue I need to be assured that the schedule will be met ... we need to move this process asap or else I may be force (sic) to stand down this fleet until the doors are modified."
A schedule provided with the released documents shows that the modification work didn't begin until late October and that new locks weren't fitted on all 188 ambulances until December 15, more than six months after Mr Sexton's accident.