UPDATE ON POSITION WITH FERNO PEGASUS TROLLEY BED –

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					UPDATE ON POSITION WITH FERNO PEGASUS TROLLEY BED – 23
MAY 2006


History:

The LAS has experienced three related quality problems with the X frames of the
Ferno Pegasus stretcher trolley bed. The outer X frame beams on three stretchers have
snapped. A number of other stretchers have exhibited permanent deformed beams
ranging from 2mm to 12m.

Pegasus trolley beds were checked by Fleet Workshops over the period 7th to 9th
April. A number of trolley beds were removed from service and replaced by Ferno
Falcon Six beds. A six weekly inspection of beds by Fleet Workshops, where the
outer beam deformation is assessed, is in operation. A maximum deformation of 7mm
is considered acceptable.

The most likely explanation for the snapping of the X frame beams on the Pegasus
trolley bed was incorrect stowage of the push/pull handles by the operator. Two
bushes are being fitted to the beds (provided by Ferno) by the Fleet Department to
prevent this reoccurring. A bulletin has also issued to staff on the correct stowage
method for the handles.

Ferno have an ongoing testing programme in place for the Pegasus trolley bed. This
aims to identify any faults in materials or design and propose actions to rectify the
issues identified.

The Medicines and Healthcare Products Regulatory Agency have been made aware of
the issues.


Three meetings have been held with Ferno, on the 11th April, 20th April and 10th May.


Proposed Actions

Following the latest meeting, Ferno are proposing the following actions:-


                      Future production of the Pegasus Stretcher Ferno would reduce
                       the hole in the X Frame beam from 14.5mm to 10.5mm
                      Ferno will be enhancing the X Frame extrusion material from
                       6063 T6 material to 6082. .
                      Strengthening Brace would be supplied in stainless steel and
                       painted in a Yellow powder coat and riveted on using stainless
                       steel rivets
                       Ferno would look to change their proposed design of the
                        strengthening brace to reduce the possibility bodily fluids of
                        being trapped; this is for infection control purposes.
                       Where the brace cannot be fitted, due to deformation, the X
                        frame beam will be replaced.
                       Write to the LAS confirming their proposal, reasons for the
                        changes, test carried out and a copy of the independent
                        consultants report confirming these changes are acceptable.
                       Following production of the braces (2/3 weeks) they would
                        supply the personnel to conduct the fitting and liaise with Fleet
                        for time and dates
                       Where the existing beams have been deformed, these will also
                        be changed before the strengthening braces are added.




Additional Points

                       Ferno have recently written to all purchasers advising them of
                        the problem.
                       Ferno have written to all Fleet Managers and Safety and Risk
                        Health managers advising them of the problem.
                       Ferno have written to the ASA (Health & Safety) advising them
                        of the problem
                       The Managing Director of Ferno UK has written to all Chief
                        Executives of the Ambulance Trusts on this problem.


Future Monitoring

A further meeting will be held to assess the progress Ferno are making with the
required work. Their final tests and consultants report will also be considered. The
LAS will consider whether a further independent report on the design and quality of
the Pegasus bed is necessary. Further discussions will also be conducted with Ferno
on the position with warranties and future production of the bed.



Chris Vale
Head of Operational Support (Acting)
23 May 2006