The HSE has been fined €500,000 for health and safety breaches which led to the death of a paramedic who fell out of a moving ambulance.
The safety breaches revolved around the presence of coach-doors on the side of the ambulance. These are doors with hinges at the rear, and if opened while the ambulance is moving they can get caught in the slipstream air rushing over vehicle.
Paramedic and father-of-six Simon Sexton (43) was killed in June 2010 when he was wrenched out of the moving ambulance by the door as a patient was being transferred from Cavan to Dublin.
Dublin Circuit Criminal Court heard that the HSE were aware of the risk after a similar incident occurred in Kerry in 2007. This incident resulted in a paramedic suffering serious head injuries. The court heard that following this, several safety recommendations were made which were not implemented by the HSE.
A Health and Safety Authority (HSA) inspector also said that at the time of the 2007 incident the HSE was waiting on delivery of about 40 ambulances with similar doors.
The manufacturers offered to alter the doors before delivery to remove the danger but the HSE refused.
Judge Mary Ellen Ring said: "A fine doesn't reflect, in any case, the seriousness of what this court is dealing with. No fine can ever restore Simon Sexton."
She said any fine imposed is not to reflect the value his life.
She added that if the problems had been dealt with after 2007 "perhaps Mr Sexton might be with us today".
Imposing the €500,000 fine she also noted the HSE "is a public body which has many demands made of it. Those demands are ever increasing and resources are ever diminishing"
The HSE pleaded guilty to failing to have a written assessment of the risks to the safety, health and welfare of an employee relating to the rear hinge side door of an ambulance on June 3, 2010, at Dr Steevens Hospital, Dublin 8.
They also admitted to failure to ensure employees had adequate training in the operation of the ambulance doors.
HSA inspector John Sheeran told prosecuting counsel Remy Farrell that after the 2007 incident the HSE hired an engineer to make recommendations on making the doors safer.
The engineer advised that warning signs be placed in the vehicle, that an improved door alarm system be installed and that a visual alarm should be mounted in the cab to indicate if the door is open.
The court heard that the HSE only enacted some of these recommendations on Mr Sexton's ambulance. Warning signs were put in place and an improved door alarm was installed, but it is not clear if it was working on the day of his death. Mr Sexton was in the back of the ambulance when he heard the wind coming into the vehicle indicating the door was not shut properly. He went to close it and as he put his hand on the lever the door opened and "wrenched him out."
His colleagues found him unconscious at the side of the road in the foetal position. He had suffered serious head injuries and died shortly after.
Following the death, an HSA investigation discovered none of the paramedics they interviewed had been formally briefed on the dangers of the door
After the 2007 incident the HSE were in the process of ordering a new batch of ambulances with the same type doors. The manufacturers offered to alter the doors at no extra cost so that the hinges were at the front but the HSE rejected the offer.
No reason was given in court for rejecting the offer but the HSE defence counsel said it was not a fiscally driven decision. The court heard that since the 2010 incident all ambulances have been altered to include front-facing hinges along with other safety measures. Defence counsel Shane Murphy offered the "sincere apologies" of the HSE for the incident.