WARNINGS about dangerous ambulance doors were ignored for three years before the death of a paramedic who fell from a moving emergency vehicle.
The Irish Independent can reveal the Health Service Executive (HSE) only took decisive measures to make the doors safe after the death of Cavan father-of-six Simon Sexton, who fell from his ambulance in June of last year.
But there was a similar accident three years earlier when another paramedic fell from an ambulance and was seriously injured.
Newly released documents show the HSE has now spent €170,000 on motion-activated locks for its fleet, which close automatically when the vehicle reaches a speed of just 2kmh.
The problem doors were located on the side of HSE ambulances and had hinges to the rear. It meant the doors caught the wind if they opened while the vehicle was moving.
This could cause paramedics to be dragged out on to the road if they tried to close them.
Concerns were raised by paramedics and unions following the 2007 incident in Co Kerry.
A source in the HSE ambulance service told the Irish Independent: "The whole idea of that door opening that way was just cracked. They used to be referred to as suicide doors."
Mr Sexton (43), from Stradone, Co Cavan, died after falling from an ambulance during a routine patient transfer last year.
The ambulance had left Cavan General Hospital to bring a patient to Dublin.
The accident is believed to have occurred when the side door of the ambulance opened unexpectedly while the vehicle was travelling at about 50kmh.
His death has been subject to three separate investigations, by the HSE, the Health and Safety Authority and the gardai.
A file was sent to the DPP in February this year but no charges have been made. A garda spokesman said that the investigation was still "ongoing".
In 2007, Kerry paramedic Declan McCrohan suffered severe head injuries after falling from the side door of his ambulance. Mr McCrohan has now taken a High Court action against the HSE.
SIPTU's southwest branch raised its concerns about the ambulance doors with the HSE following that incident.
Regional organiser Ted Kenny, speaking shortly after Mr Sexton's death, told the Irish Independent: "We would be horrified to think this man may have lost his life from a situation we raised three years ago."
He specifically cited the door-locking system on rear-hinged doors as an area of concern that had been raised with the HSE.
Despite the 2007 accident, the ambulances weren't removed from service or modified and no mandatory motion-activated locks were specified in tender documents for a large HSE ambulance order in 2009.
Projected to cost between €20m and €30m, the tender for more than 90 ambulances and other vehicles was published in June of that year.
The tender called for "audible and visual" indicators in the vehicles to make the driver aware if doors in the patient compartment were open.
It wasn't until the following year that the HSE initiated a mini-tender competition, which required that "all doors of the ambulance will automatically lock upon movement of the vehicle. When in motion, the doors in the rear of the vehicle will not open".
The HSE confirmed that it spent €167,787 getting the locks fitted to 188 of its ambulances.
Asked why motion-activated locks weren't fitted after the Co Kerry accident and weren't a requirement in the 2009 ambulance tender, a HSE spokeswoman said: "The incident investigation in 2007 did not identify this as a recommendation."
She said that after the 2007 accident "staff were advised to ensure that all ambulance doors were properly closed and secured before moving off on journeys" and warning signs were posted in the vehicles.
Ambulance crews were also instructed to check that "audible and visual warning systems were operating as designed".
Asked if the HSE was satisfied that adequate measures to prevent a recurrence of the 2007 incident had been taken, she said: "The HSE complied with the recommendations made."