MISTAKES made by companies organising a trekking holiday in Nepal contributed to the death of an Orpington woman who developed altitude sickness, an inquest has heard.
Rachel Burke, of Rushmore Hill, Orpington booked a three-week trip organised by The Adventure Company (TAC), based in Crawley, West Sussex, and its contractor in Nepal, Himalayan Encounters.
Both companies had a code of practice stating walkers should ascend no more than 300 to 500 metres per day, yet they approved an itinerary which saw Rachel ascend 610 metres in one day.
Southwark Coroners Court heard the 28-year-old struggled to keep up, and arrived some time after the rest of the group in the village of Machermo.
Rachel's housemate and companion on the trip Becky Everest, said: "The day before she died, Rachel struggled to keep up with the rest of the group, felt unwell, had a cough and had trouble sleeping."
Rachel loved to travel and adventure.
Fellow trekker Rachael Garner noticed Rachel's lips were blue when she arrived at the teahouse where the group slept that night.
She said: "Next morning, on the day she died, Rachel said she was OK.
"But in fact she was exhausted and couldn't pack her own bag. I did it for her.
"She lacked the hand-eye co-ordination to be able to tie her own shoelaces.
"I thought she'd reached the point where it was unwise for her to carry on with the trek and she should go back down the mountain."
Tour leader Ashok Phuyal decided Rachel was too fatigued to continue, but he failed to send her to the rescue post manned by UK doctors, just ten minutes' walk away in the same village, or summon a helicopter to airlift her off the mountain.
Instead he sent Rachel with an assistant guide who did not speak fluent English and wasn't trained in altitude sickness, to walk down the mountain to another village.
She was too ill to reach it and ended up descending to another village, Dole, just 400 metres down the mountain.
After arriving in Dole her condition deteriorated rapidly and she died in the early hours of April 23, 2011.
Rachel with her mother Maureen.
Coroner Dr Andrew Harris said Mr Phuyal failed to fully recognise the symptoms of advanced mountain sickness, failed in sending Rachel to walk back down the mountain and failed to send somebody properly trained in altitude sickness to accompany her.
He also ruled there was negligence in failing to provide Rachel with basic medical care by taking her to the doctors at the Machermo rescue post once she became ill.
Representatives of both companies insisted the trip was subject to a rigorous risk assessment, but TAC's health and safety manager, Zoe McAndrew, admitted the fact that the ascent on the trek's toughest day breached the safety guidelines "escaped my notice".
Dr Harris recorded a narrative verdict, saying the companies failed to ensure the itinerary complied with their own safety guidance.
Michael Edwards, UK and Europe Director of The Adventure Company, said: "The Adventure Company was shocked and saddened by Rachel Burke’s death and extends its deepest sympathies to her family and friends for their loss.
"The company has been organising adventure tours for 18 years and working with Himalayan Encounters, our local operator in Nepal, for 13 years.
"We have taken hundreds of trekkers along this well-trodden route and this is the only incident of this nature that has occurred.
"The Adventure Company takes the health and safety of all our passengers very seriously and since Rachel's death we have taken a number of steps to strengthen the procedures that our local operator follows and to increase the safety equipment carried on treks."