The Attorney General v John Sutherland and Tom Le Sauteur

Inferior Number Sentencing - Health and Safety [2024]JRC167 Royal Court (Samedi) 16 July 2024 Before : Sir John Henry Boulton Saunders, Commissioner, and Jurats Ronge and Entwistle The Attorney General -v- John Sutherland Tom Le Sauteur Sentencing by the Inferior Number of the Royal Court, to which the accused were remanded following conviction at Inferior Number Trial to the following charge: John Sutherland 1 count of: Contravention of Article 21(1)(a) of the Health and Safety at Work (Jersey) Law 1989, as amended Age: 61. Plea: Not guilty. Details of Offence: The Defendants in their roles as paramedic (Sutherland) and technician (Le Sauteur) with the Ambulance Service, attended Mr Irvine’s address following a self-reported overdose. The Defendants alleged, as was accepted by the Jurats, that Mr Irvine was initially aggressive towards the Defendants, resulting in them calling for police assistance. Whilst the standard of care offered initially in the face of the aggression was accepted as being reasonable, upon police attendance the Defendants failed to assess and manage Mr Irvine’s airway prior to his cardiac arrest, to assess and manage a patient with a reduced level of consciousness, to take steps to protect Mr Irvine from harm which may lead to loss of life and to provide a reasonable standard of care without any unreasonable delay. Mr Irvine sadly passed away whilst the

Defendants and police officers attended to him. There was no evidence that his life would have been saved if the Defendants had acted differently. The Defendants were convicted following an 8-day Inferior Number trial. Details of Mitigation: Previous good character and positive good character, including in the context of their employment within the Ambulance Service. Delay and the impact on the Defendants and their families. Previous Convictions: None. Conclusions: Count 1: £5,000 fine. Costs sought in the sum of £1,500. Sentence and Observations of Court: Count 1: 2-year conditional discharge imposed. Costs ordered in the sum of £500 towards the Prosecution’s costs. The Court took the view that this was an exceptional case. The Defendants’ acts were not to be treated as malicious ones but rather a result of misjudgement. The Court took into account the Defendants’ positive good character, the reputational damage and significant delay whilst proceedings hung over them. Tom Le Sauteur 1 count of: Contravention of Article 21(1)(a) of the Health and Safety at Work (Jersey) Law 1989, as amended Age: 36. Plea: Not guilty. Details of Offence: See above. Details of Mitigation: See above. Previous Convictions: None. Conclusions: Count 1: £5,000 fine. Costs sought in the sum of £1,500. Sentence and Observations of Court: Count 1: 2-year conditional discharge imposed. Costs ordered in

the sum of £500 towards the Prosecution’s costs. The Court took the view that this was an exceptional case. The Defendants’ acts were not to be treated as malicious ones but rather a result of misjudgement. The Court took into account the Defendants’ positive good character, the reputational damage and significant delay whilst proceedings hung over them. L. Sette Esq., Crown Advocate. Advocate I. C. Jones for Defendant Sutherland. Advocate F. J. Littler for Defendant Le Sauteur.

JUDGMENT THE COMMISSIONER: 1. On 26 June 2024 these two Defendants were found guilty by the Court of an offence under the Health and Safety at Work (Jersey) Law 1989 of failing to take reasonable care for the health and safety of Frazer Irvine 2. Although I gave a short judgment explaining the decision of the Court when I announced the verdict of the Court, it is necessary to give a rather longer judgment now to put the sentence which the Court will impose in its proper context. The Offence 3. Article 4 of the Health and Safety at Work (Jersey) Law 1989 creates a duty on any employee while at work. The nature of that duty is to take reasonable care for his or her health and safety and the health and safety of other persons who may be affected by his or her acts or omissions. Article 21 makes it an offence to fail to discharge a duty to which the person is subject by virtue of Part 2. Article 4 is part of Part 2 of the Law.

4. The Legislature passed the law which created this criminal offence, and it was for the Attorney General to decide whether, in the circumstances in which this offence was said to have happened, it was in the public interest to prosecute. He decided it was and it was then the duty of the Jurats to decide the allegation on the evidence applying the criminal standard of proof; that is that they would only convict if sure of guilt. If they were sure of guilt, it was their duty to convict.

5. The Attorney General particularised the ways in which he said the offence had been committed by amending the summonses. He alleged that the Defendants failed: “a. To assess and manage Frazer Irvine’s airway prior to his cardiac arrest; b. To undertake initial clinical observations of Frazer Irvine prior to his cardiac arrest; c. To undertake initial and ongoing assessment of Frazer Irvine’s physical condition; d. To assess and manage a patient with a reduced level of consciousness; e. To observe clinical practice standards in delivering resuscitation; f. To provide a reasonable standard of care without any unreasonable delay; g. To take steps to protect Frazer Irvine from harm which may lead to loss of life.” 6. The Court heard a great deal of evidence. The Prosecution and Defence both instructed pathologists and experts in pre-hospital care. Before the hearing the pairs of experts were asked to meet and set out in a document what they agreed on and what they disagreed on.

7. In addition to considering a great deal of evidence the court went on two site views. The first was during daytime when an ambulance also attended to give the court a better idea of the layout when the Defendants attended the scene. A dummy was supplied that was much smaller and lighter than Frazer Irvine to give the Jurats some idea of the difficulties that the Defendants faced while trying to cope with Frazer Irvine on the night of the incident. The second view was at nighttime which gave the Court a better idea of what the scene was like at night. It was not possible to recreate the conditions exactly, but Mr. Le Sauteur’s evidence was that the light was similar to how it was on the night of 18 March 2022 which is when these events happened.

8. At the time of this offence Mr. Sutherland was a very experienced paramedic who had a long history of senior roles in the Ambulance Service. Mr Le Sauteur was an ambulance technician who had experience in working in the army medical corps and other medical technician roles on the island. As a technician he had less training than Mr Sutherland but no one disputed that he had the necessary knowledge of what was essential to save life as the Court was told he had done in the past. They were both very highly regarded by their colleagues both in the skill with which they carried out their work and their compassion towards patients. All this evidence of positive good character the Jurats took fully into account in accordance with my legal directions.

9. The basic facts of what happened on this night are not in dispute. In setting out the outline I shall use the account given by the Defendants except in so far as the Jurats are sure it is incorrect. Frazer Irvine may have had a different account, but we cannot know what it would have been. Where there is any objective evidence, I have incorporated that, where it is relevant.

10. At 22.19 on 18 March 2022 Frazer Irvine, a 39-year-old man, called for an ambulance because he said that he had taken an overdose. In that call he stated he had “taken everything” and “a lot of pills”. He lived at Les Greffes Farm in a first floor flat with access to the front door via an outside staircase which ends on a landing giving access to the front door. At 22.27 the ambulance crewed by the Defendants was despatched to the scene. There were no warnings attached to the despatch to indicate that Frazer Irvine had been violent in the past when ambulances had attended his address. That was because there was no record that he had been. He had on one occasion sworn at a paramedic who came to help him but had not exhibited actual violence. Swearing at an ambulance crew would not result on its own in a warning being attached. The Defendants were told that the report was of a drugs overdose. The location of Les Greffes Farm was difficult to find but the ambulance arrived in 9 to 10 minutes after guidance had been provided.

11. When the Defendants got out of the ambulance, they did not take their paramedic’s bag which contains basic lifesaving equipment with them, which would have been normal procedure. The Defendants explained that they did not know where Frazer Irvine’s flat was in the compound, and they did not want to get the bag out until they had located the flat. It would have been of assistance if it had been on site when Frazer Irvine had his cardiac arrest. While it might have been unusual not to take the bag when attending a suspected overdose the Jurats, having heard the Defendants’ explanation, considered it came within the range of reasonable responses by a competent paramedic or technician.

12. Once the Defendants were in the flat, they say that Frazer Irvine was verbally aggressive and seemed drunk. He had consumed a significant amount of alcohol, as forensic tests were to confirm later. There were also half empty blister packs of drugs in the flat. The Defendants initially assessed that Fraser Irvine was well perfused and that he showed no signs of distress or breathing difficulties. They nevertheless concluded, in accordance with their training, that Frazer Irvine needed to be taken to hospital to be properly checked over. The Defendants did their best to persuade Frazer Irvine to come with them, but he continued to be aggressive. The Defendants say that Frazer Irvine took up a boxing stance and one of them says that he threw punches although they did not connect. At one stage the Defendants managed to get Frazer Irvine out of the flat and on to the relatively small landing immediately outside the front door in their attempt to get him into an ambulance.

13. Because of Frazer Irvine’s violent response and the risk to their safety, the Defendants decided that they could not get him to hospital without assistance from the police. Having made that decision the Defendants were entitled, as they did, not to take any action which might result in a violent response. They were perfectly entitled to call the police and wait for them to arrive before they carried out any treatment or tests. They are under a duty to take reasonable care for their own safety, and they were entitled to conclude that it would not be safe to continue with trying to get Frazer Irvine to hospital until the police came or to do anything which might put either of them in physical danger.

14. The Court makes no criticism whatsoever of that decision. The Defendants were on a small landing which had guard rails with gaps between them and they were dealing with a very large and possibly violent man. Their decision to call the police cannot be and has not been criticised.

15. The Defendants say that they made two phone calls asking for police backup. The first one fairly soon after their arrival and the second a follow up call at 22.52 asking where the police backup was.

16. The prosecution accept that a call was made at 22.52 calling for police assistance but say that no earlier call was made. The evidence relating to whether there were one or two calls is contradictory and the Jurats were unable to reach a firm conclusion either way. In the event they have decided that it was not a decision that they need to make as the opinion of the Defence expert was that even if there was only one call made at 22.52 it was not unreasonably delayed. The Jurats accept that.

17. There is a CCTV camera fixed on a corner of the building which gives some idea of what happened on the balcony after Frazer Irvine came out of his flat up until the arrival of the police. The CCTV imagery is somewhat grey and indistinct despite the enhancement that has been done on it. It is possible to get a general idea of what is going on but no more than that.

18. To start with when on the landing Frazer Irvine goes down onto his knees and later lies flat on the floor. He does come back on to his knees perhaps more than once and the Defendants say that at the early stages they were having to prevent Frazer Irvine from throwing himself down the stairs and that he was still being aggressive. Mr Sutherland at one stage goes to the ambulance collects a jacket and then returns to the steps. For most of this period before the police arrive, the Defendants remain standing on the landing and, as time goes on, the movements of Frazer Irvine become less and he is seen to be lying down on the landing. A blanket is placed on him which is collected from the flat in order to keep him warm and, while there was some criticism of this from the prosecution expert on the basis it could mask any view of breathing difficulties, the Jurats agree with the Defence expert that it seemed a sensible step to take.

19. The Jurats have concluded from the CCTV, from the evidence given by the Defendants and the opinions of the experts that over this period the condition of Frazer Irvine was deteriorating. His consciousness level had changed to the extent that the police were told by the Defendants, when they the police arrived, that Frazer Irvine had fallen asleep. He had started to vomit during this period, as can be seen from the body worn video images taken by the police when they arrived.

20. After the arrival of the police, Frazer Irvine was lying in a semi-prone position with his face partially in vomit which was immediately in front of his mouth on the top landing on the staircase and then dripping down on to the step beneath. He was making noises indicative of the fact that he was breathing through vomit. Frazer Irvine’s hand was also in front of his mouth for some of the time, which appeared to have partially occluded his airway. He was making some movements, but it should have been clear to either a competent ambulance technician or paramedic that his level of consciousness was now reduced. Attempts by the police to get Frazer Irvine to respond were only successful to a limited extent so that they continued to shout at him. However, at that stage there was no indication that the Defendants had reassessed Frazer Irvine’s condition or made a further dynamic risk assessment.

21. There was then a discussion between the police and the Defendants about what was going to happen next, and it was decided that Frazer Irvine should be moved to the ambulance and taken to the hospital. The Defendants had had to decide whether to take Frazer Irvine to the ambulance and then to the hospital or to carry out tests and provide some treatment, if necessary, on the landing. If the decision was to take him to hospital and carry out tests on the way, it was important that he was moved as quickly as possible, as patients who have taken an overdose may deteriorate very quickly.

22. In the event the Defendants decided to move Frazer Irvine to the ambulance and then to hospital. That needed to be discussed with the two police officers who had arrived as it involved manhandling the patient down the stairs. The Jurats consider this would have been a reasonable plan providing it was carried out expeditiously. Having agreed the plan, it was necessary for the Defendants and eventually the police officers to put on personal protective equipment before Frazer Irvine could be moved. Also, the trolley needed to be moved to the bottom of the staircase to transport the patient from there into the ambulance.

23. All of this took time and during that time Frazer Irvine was left lying in or close to vomit; making noises indicating that his breathing was being obstructed and with an apparently low level of consciousness. Mr Le Sauteur did say during his evidence that he believed that Frazer Irvine had responded to a question asked of him which would put his level of consciousness at a higher level than the experts believed it to be. It is fair to say that Mr Le Sauteur was unable to say whether he heard that at the time or whether it is something that he believed he had heard on the body worn video while examining it for the purpose of this trial. It certainly was never referred to in his interview with the police which included a prepared statement as well as answering questions. The Jurats have listened with great care to the body worn video and it is certainly not easy to identify a response being given rather than just an involuntary noise.

24. For some of the time while the Defendants were making preparations to take Frazer Irvine to the ambulance, one of the police officers, PC Buckley, was left to ensure that Frazer Irvine was safe. While the Defendants may have assumed that the police officer would be trained in ensuring that an airway was maintained, they ought to have checked that he knew what to look out for and they were not themselves showing concern that Frazer Irvine’s breathing could be obstructed. Mr Sutherland was the first of the Defendants to return to the landing having put on his protective clothing, but he did not make any examination of Frazer Irvine to ensure that his airway was clear. He then went to check in the flat to see what drugs had been taken by Frazer Irvine.

25. When Mr Le Sauteur returned to the staircase, he did nothing initially but then did clear up the vomit at the suggestion of PC Wilton. She queried Frazer Irvine’s breathing and a possible change of colour. Mr Le Sauteur did not immediately react to these queries but suggested that Frazer Irvine was alright. Mr Le Sauteur in evidence said that possibly he did not notice the colour change because he suffers from some degree of colour blindness. This does not mean that he should not have reacted more quickly to what PC Wilton said to him.

26. Mr Le Sauteur did become concerned when Frazer Irvine began to show signs of deterioration consistent with going into cardiac arrest. The police officers assisted the Defendants to make resuscitation attempts and equipment was brought from the ambulance to test and shock the heart if appropriate and to provide oxygen. This did take a little time but in any event the efforts to save Frazer Irvine were not successful and he died at the scene.

27. Following concerns about the care given to Frazer Irvine as a result of studying the body worn video, an investigation was commenced by the States of Jersey Police, who after a period of investigation, decided not to prosecute but handed the case to the Health and Safety Inspectorate to consider possible charges under Health and Safety legislation. Experts in pre-hospital care were instructed by both the Prosecution and Defence, as were pathologists. Both sets of experts having prepared reports discussed their conclusions to identify where they agreed and where they disagreed. There was no disagreement between the pathologists who produced a joint report and while there were disagreements between the pre-hospital care experts there was also a significant amount of agreement.

28. The most relevant agreed findings of the pathologists were: (i) The background circumstances of the case, and findings at the scene, are strongly supportive of a combined drug and alcohol intoxication leading to a reduced conscious level, vomiting, and subsequent cardiac arrest. (ii) It is clear from body worn video footage that Mr Irvine was suffering from a significant impairment of conscious level and vomiting in the lead up to his cardiac arrest. (iii) Toxicological analysis showed that Mr Irvine was under the influence of alcohol at the time of death. His blood alcohol concentration was 209mg/100ml, just over 2½ times the legal limit for driving which would undoubtedly have had an effect on him. (iv) Also on toxicological examination various drugs were also found to be present which had been found in the flat. These were, individually, not at concentrations that would be expected to result in a toxic effect but in combination with alcohol it is possible that the combination of drugs and alcohol could have resulted in a reduction in conscious level. (v) During the available footage Mr Irvine could be seen lying with his face in a pool of vomitus and vomiting with his hand up against his face. This represents a high-risk scenario for aspiration of vomit. (vi) Prompt effective medical attention will always give a patient the best chances of recovery, but it is not

possible from the pathological findings to determine whether or not a different approach by paramedical staff would have altered the fatal outcome. (vii) The cause of death is given as: “1a) Cardiorespiratory arrest occurring on a background of mixed alcohol and drug use (diazepam, mirtazapine, quetiapine) and aspiration.” 29. The Prosecution pre-hospital expert was Professor Charles Deakin, a highly qualified expert who has assisted in preparing the JRCALC Guidelines (which have been adopted in Jersey) for those who work in pre-hospital medicine including paramedics and technicians. He also has considerable practical experience in attending pre-hospital emergency calls with Ambulance and Air-ambulance services in the UK. The Defence expert, Mr Timothy Edwards, is a very well qualified consultant paramedic who has given expert evidence in a number of cases. The Jurats found the evidence of both of these experts to be of assistance.

30. In two principle respects the pre-hospital experts agreed that the Defendants fell below the standard to be expected of a reasonably competent paramedic and technician. First at para 2.2 of their joint report they said this: “In relation to maintaining an airway the JRCALC guidelines state: Correct any airway problems immediately by: Positioning – head tilt, chin lift, jaw thrust. Suction – (if available and appropriate) We both agree that from the point of the commencement of police body worn camera footage, no attempt appears to have been made to improve Frazer’s airway by positioning or moving him into the recovery position. Suction was available (stored in the ambulance) and appropriate, but not used prior to the cardiac arrest. We both agree that Paramedic SUTHERLAND and Technician LESAUTEUR therefore failed to meet the standard to be expected of a reasonably competent paramedic & technician with regards to assessing and managing Frazer’s airway from the commencement of police body worn camera footage, until prior to his cardiac arrest.” 31. Mr. Edwards modified this view to an extent in his evidence, as he said that the Defendants had chosen to take the option of removing Frazer Irvine to the ambulance and then to the hospital rather than treating him at the scene. He went on to say that this had to be done quickly, which it was not. This meant that, as a minimum, inadequate attention was paid to Frazer Irvine’s airway while preparations were made to take him to hospital.

32. The second area where the two pre-hospital experts agree that the Defendants fell below the standard of reasonable practice was when the Defendants returned from putting on personal protective equipment. Frazer Irvine was, in the view of the experts, showing signs of deterioration which were not dealt with quickly enough. Mr Edwards the defence expert said on the agreed document “On returning to Mr Irvine after donning personal protective equipment, I am of the view that signs of significant clinical deterioration were missed, resulting in some delays in undertaking time critical interventions relating to airway management, oxygenation and ventilation. In my opinion these aspects of care would not be regarded as within the bounds of reasonable and responsible practice.” Professor Deakin, the Prosecution expert, agreed with that statement.

33. In reaching their decision, the Jurats bore in mind that the Prosecution had to reach the criminal burden of proof before there could be a conviction and they had at the forefront of their considerations the positive good character of the Defendants. Not only have the Defendants not committed any offence in the past but their abilities at carrying out their jobs have been described in the highest terms by their colleagues. That is relevant not only to whether the Jurats believed the Defendants’ evidence but also whether it was likely that they would have treated Frazer Irvine in other than a caring way. The Jurats have, as they were bound to, considered the case of each Defendant separately. In the case of Mr Le Sauteur, they have taken into account that as a technician as opposed to a qualified paramedic, he has had less training and could not carry out certain procedures which Mr Sutherland could.

34. The Jurats have concluded that there are two areas where the Defendants failed to take reasonable care for the safety of Frazer Irvine. The first was when the police arrived, and it was safe to examine his condition. There was no dispute at the trial that it was safe to carry out at least a superficial examination after the police had arrived and were on the staircase. The position that Frazer Irvine was in was not ideal for ensuring that his airway was kept clear, as both the experts agreed. His head was lying in or at the edge of vomit which caused a risk of aspiration of vomit. The pathologists both agreed that Frazer Irvine had a reduced level of consciousness at this stage and the way in which he was lying created a high risk of aspiration of vomit which could block the airway. If the airway is sufficiently impeded this can have serious consequences. While the decision was taken to get Frazer Irvine to hospital as soon as possible that could not and did not happen immediately. Therefore, each of the Defendants should have ensured that Frazer Irvine was not at risk of aspirating vomit as far as that was possible before he reached the hospital. Both Defendants were well aware of the need to ensure that the airway of a patient is kept clear.

35. The second area where the Jurats have concluded that the Defendants failed to take reasonable care for the safety of Frazer Irvine was after they had put on personal protection and returned one after the other to the steps where Frazer Irvine was. By then Frazer Irvine was showing signs of having deteriorated and, as we now know and with the benefit of hindsight, a cardiac arrest was imminent. At the time that Mr Sutherland returned to the steps, it was apparent that Frazer Irvine was still not going to be moved to the ambulance immediately. In those circumstances he should have checked for signs of deterioration and at the least should have cleared the vomit away from the area of Frazer Irvine’s face. Instead, he went into the flat to check what drugs had been consumed so that the hospital could be given that information to help with finding the appropriate treatment. While that was necessary, it could have been done by one of the police who could follow in the police car rather than delay the ambulance taking the patient to hospital. Mr Sutherland seemed to accept in his evidence both those criticisms while maintaining his position that he had not failed to take reasonable care for the patient.

36. In relation to Mr Le Sauteur, he also failed to act sufficiently promptly when he returned to the staircase. He had to be prompted by PC Wilton to clear away the vomit from around Frazer Irvine’s mouth. He did not react sufficiently quickly to her query as to Frazer Irvine’s breathing and his change of colour. As the Defence expert explained, taking steps to clear the airway at this stage was time critical and Mr Le Sauteur did not give the immediate response which was required.

37. Finally, the Jurats have looked with care at the speed at which things happened at the scene by considering the body worn video images a number of times. While accepting and understanding that things can look different in real life than on video images, there did not seem to be the sense of urgency to remove Frazer Irvine to hospital that there should have been. The police officers were never told expressly that the removal should happen quickly. While the police officers were not critical of the way the Defendants carried out their responsibilities, they did not have the medical training to understand the urgency or the risks that there were to Frazer Irvine concerning his ability to breath and the consequences of not having a clear airway.

38. It follows and is important that the Jurats are not critical of anything that the Defendants did or did not do before the arrival of the police. They were obliged to take reasonable care for their own safety. But once the police had arrived and were near the top of the staircase there was no danger involved in providing reasonable care to Frazer Irvine as he lay there, as can be seen clearly on the video. Neither Defendant has suggested they were prevented by Frazer Irvine at that stage from providing reasonable care.

39. While criticisms have been made of the treatment given by the Defendants after the cardiac arrest, the Jurats have borne in mind the conditions in which the Defendants were working to try and save a life and that the police officers who made up the rest of the team were inexperienced in carrying out medical procedures. It should be noted that all the witnesses have praised the effort that the police did make in that emergency. The Jurats in those circumstances are not satisfied that the Defendants failed to take reasonable care for Frazer Irvine’s safety when attempting to resuscitate him after his cardiac arrest.

40. Accordingly, for the reasons that I have given, the Jurats are sure that particulars a) d) f) and g) in the summons are made out. On the basis of those findings the Jurats are sure that the Defendants did not take reasonable care for the health and safety of Frazer Irvine in the ways that I hope I have made clear. How and why did this happen?

41. The Jurats accept that this was an exceptional case, and they are very conscious of the invaluable work done by the ambulance service often in very difficult conditions. These Defendants have on the evidence in the past lived up to the very high professional standards of the ambulance service and there is no reason to suppose that they would not do so in the future. On this occasion they fell well below their own very high standards. They did not put Frazer Irvine in danger deliberately, but it does seem they lost sight of what was happening to Frazer Irvine after the police arrived but before he received help. Whatever the Defendants were thinking about whether Frazer Irvine had taken a drug overdose, there was no basis on what they found to assume that he had not overdosed. They did not seem to take their patient’s condition as seriously as they should have done on the evidence they were presented with and therefore failed in certain respects to perform to the standard and with the urgency that was required in these particular circumstances.

42. So having set out the context with which sentence has to be passed I now move to that. The Court is grateful for the submission of the advocates in what is a very difficult case. Having considered all those submissions, the Court has decided that in this case it is not appropriate to impose a fine and accordingly it will impose on both Defendants a conditional discharge for a period of two years. The reasons for that in brief are as follows.

43. Firstly, the Court has taken into account the positive good character of the Defendants. Mr Sutherland had been a paramedic for a very long time and reached high office in the ambulance service. Mr Le Sauteur has not worked as an ambulance technician for as long, but he is highly regarded by his colleagues. That good character and reputation has now been damaged and that will be a serious blow to both of them.

44. We do regard the delay as significant. They have both been suspended for more than two years and furthermore they have had to wait for disciplinary proceedings to find out whether they will keep their jobs for that period of time. This has caused, we are satisfied, considerable stress for the Defendants and their families.

45. The Jurats, as I have already said, have concluded this was not a malicious act on the part of the Defendants but was a result of misjudgement. In all the circumstances of this case as well it is very difficult to assess a suitable level of fine to reflect those circumstances. The meaning of a conditional discharge is this, it will remain in force for two years and in the unlikely event that either of the Defendants commit any further offence during that period of two years then they can be resentenced for this offence. If there is no further offending during that period that will be an end of the matter and no doubt in any disciplinary proceedings the ambulance service would wish to take account of the penalty which has been imposed.

46. I now come finally to costs. While there is no rule in criminal cases that costs follow the event, if there is a successful prosecution which involves the State in cost then there is no reason why a Defendant should not pay all the costs if he or she can afford it or make a contribution if they can only afford a contribution. Accordingly in this case, where no financial penalty has been imposed the Court is satisfied that the Defendants can make a fairly minimal contribution towards the costs and in those circumstances the Court orders that each of the Defendants should pay a contribution towards the costs of the Prosecution of £500 each. Authorities Health and Safety at Work (Jersey) Law 1989. R v F and Howe and Son (Engineers) Limited [1999] 2 Cr. App. R. (S) 37 AG v Petroleum Distribution (Jersey) Limited [2018] JRC 190 AG v CNR Construction [2022] JRC 050 Sentencing Council Guidelines