The jury made nine recommendations, including the use of motorbike ambulances, the deployment of at least two ambulances, and stationing a 24-hour on-duty medical officer on each of the populated islands. Other recommendations included keeping comprehensive resuscitation equipment at rural clinics, improving police equipment and transport on outlying islands, and pursuing a more efficient and flexible deployment of police manpower.

Coroner Michael Chan Pik-kiu said the court would forward to relevant departments the recommendations to improve the response of medical services.

Slough, a journalist with an in-house police publication, died the day after the fall. The court heard that an ambulance arrived at the scene and took Slough to a clinic about 30 minutes after the accident happened at about 6pm.

Li Wai-keung, a senior ambulance officer, told the court he and his team were in the North Lamma Clinic, helping nurses resuscitate a man who had hanged himself, when he received a call from the control office to rescue Slough. Mr Li said there were only two nurses on duty at the clinic when Slough arrived, and that it was 'a long time' before a doctor arrived.

Outside court yesterday, William Giles, the solicitor for Slough's widow, Leung Mui-ying, said his client was not blaming any departments for the tragedy. But she believed it was her duty to determine the facts and to help residents of outlying islands who could benefit from the jury's recommendations.

The Fire Services Department said each populated outlying island - Lamma, Cheung Chau, Ping Chau, Mui Wo, Cheung Sha and Tai O - had only one ambulance.

The department and the Hospital Authority said they would study the recommendations and give them serious consideration.