Recurring concern

Unreliable safety arrangements for lone workers

Pin Get email alerts Request correction

First reported 29 Jun 2015•Latest report 8 May 2024

Definition

What this concern includes

Includes dedicated lone-working controls across operational, security, care and workplace settings, including risk assessment, check-in or welfare-check arrangements, supervision, communication, emergency assistance and escalation when a lone worker cannot be contacted or requires support.

Not included

  • Excludes ordinary staffing, supervision or welfare-check failures where lone working is not a material part of the unsafe condition.
  • Excludes generic emergency-response, communication or personal-protective-equipment deficiencies unless they are specifically part of a lone-working safety arrangement.
  • Excludes remote-site supervision concerns where the material issue is site remoteness rather than the worker being alone.
  • Excludes the underlying workplace or environmental hazard when no deficiency in the dedicated lone-working arrangement is identified.
Reports
8

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2015–2024

First to latest report issue date

Stated actions
6

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Blatchington Mill School1
Brighton and Hove City Council1
Canary Wharf Management Limited1
Care Quality Commission1
Central Medical Services Ltd1
Department of Health and Social Care1
Future Health and Social Care Association C.I.C.1
KK Security & FM Ltd1
London Underground Limited1
Midlands Partnership University NHS Foundation Trust1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1
Tesco Stores Limited1
Wayland Prison1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Sean Patrick O’CONNOR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sean O’Connor was electrocuted shortly after 10am on 24 November 2021 while changing a heat pump flow switch terminal during work in London. The report raised concern that lone workers might not receive the checks contemplated by the risk assessment, and that routine site discussions should remind workers whether checks are required during the day.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure required daytime checks on lone workers

    Wider context from the report

    “I heard evidence at inquest that, as he was regarded as a lone worker, Sean O’Connor could and, according to the risk assessment method statement (RAMS), should have asked a CWML colleague to come to check on him during the day. He did not ask for such a check and, although a CWML employee thought of doing so, that person was busy and so did not. Whilst such a check is likely to have taken place too late in the day to have changed the outcome for Mr O’Connor, that might be different for another lone worker. Several witnesses gave evidence that discussions take place with every worker coming on site as a matter of routine, covering such matters as where the worker is meant to be located, the exact nature of the job and so forth. The CWML director who gave evidence at inquest agreed with me that it would be a straight forward matter to include within that as a point always for brief discussion, whether any checks are required during the day. In this way, if the operative forgets to ask, the discussion can act as a reminder. ”

    Source location

    Sean Patrick O’CONNOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Trial a welfare-check process for lone workers applying for work authorisation, including prompts, competent-person checks, and system recording.

    Verbatim wording from the response

    “Notwithstanding the above, and as part of a process of continuous improvement, CWML has decided to trial a new feature to apply to WA, beginning July 2024. The arrangements will include:”

    Source location

    Response from Canary Wharf Management
    Page 1 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the six-month trial, assess its effectiveness, and decide whether further changes are needed.

    Verbatim wording from the response

    “These arrangements will apply in addition to the independent contractors' procedures for lone working. The trial is intended to run for 6 months at the end of which CWML will review the results, consider their effectiveness and decide whether to implement some or all of the trial or make any further changes.”

    Source location

    Response from Canary Wharf Management
    Page 2 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update the Contractor Handbook and Lone Working Policy to apply to contractors.

    Verbatim wording from the response

    “In addition to the above, CWML will be updating the Contractor Handbook and the Lone Working Policy to apply to contractors.”

    Source location

    Response from Canary Wharf Management
    Page 2 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The existing risk-based system and checks are considered adequate, and broader checks could divert resources from higher-risk work.

    Verbatim wording from the response

    “CWML’s approach to facilitating access to its premises by independent contractors reflects what it understands to be recognised practice. CWML is not aware of any concerns raised by contractors (including Mitsubishi) before the incident involving Mr O'Connor. The existing CWML system prioritises checks based on risk (higher risk works requiring a PtW involve mandatory checks and are rarely performed by lone workers). CWML is mindful of the need to avoid potentially undermining the strengths of the system by diverting resource away from higher risk works.”

    Source location

    Response from Canary Wharf Management
    Page 1 · response
    Published 14 May 2024

    Open published response

  2. Brighton and Hove

    AI-generated summary

    David Alexander MOBS​​BY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Alexander MOBS​​BY fell while working at Blatchington Mill School on 3 August 2018 and was found unconscious after working alone. The report raises concerns about inadequate health and safety arrangements for work at height, lack of training, supervision and risk assessment, and delays in providing CPR, including the absence of a first aider or designated person on site.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to control lone and unsupervised working

    Wider context from the report

    “(1) Brighton and Hove City Council were “advising” Blatchington Mill School (BMS) on health and safety. They were apparently using a template which made no mention of work at height when considering the health and safety of the facilities (caretaking/cleaning) department at BMS. This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height. (2) Although Mr MOBS​​BY was employed either by Brighton and Hove City Council or BMS or a combination of the two, he was not monitored or instructed in his work. He was allowed to choose how, when and where he worked. Even though anyone who knew his job description or knew Mr MOBS​​BY was aware that he was using ladders and step ladders he was untrained with regard to working at height. • On the 3rd August 2018 he was unchallenged when he announced his work programme for the day. • His line manager’s did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers. • No methodology was explored when he announced his job for the day, there was no discussion about the equipment that he was going to use. • There was no risk assessment undertaken in respect of any of the jobs that he did. • He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day. • His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade. • He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 hrs having taken one forty minute break at 1100 hrs. • It seems clear that working at BMS formed a huge part of Mr MOBS​​BY’s life. He had been there for many years and was probably set in his ways and not amenable to being managed. • Those managing him were all relatively new to their managerial posts and yet none of them had received any management training. It was clear they had no idea how to deal with him. • They were not assisted by the fact that it was supposed to be the case that every employee was appraised annually. • There was no evidence at all to suggest that Mr MOBS​​BY had ever been appraised. I am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and I think the matters raised in it should have wider discussion throughout the Country. ”

    Source location

    David Alexander MOBS​​BY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    Dr Polly Joanne Drew · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dr Polly Joanne Drew, aged 35, died by suicide after injecting herself with Propofol and Atracurium acquired from the medical centre where she worked as a duty doctor. The report raised concerns that Central Medical Services’ recruitment process was inadequate, including not obtaining written references or completing a DBS check, despite her access to anaesthetic drugs and working alone.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Potential significant risk from doctors working alone while medically responsible for members of the public

    Wider context from the report

    “1. The recruitment process for the appointment of a Doctor to a position of such significant responsibility, with access to anaesthetic drugs, is completely inadequate. None of the above appears to have been known to ████████ when Dr Drew was appointed. Dr Drew worked alone, putting herself and members of the public, for whom she had medical responsibility, at potential significant risk. ”

    Source location

    Dr Polly Joanne Drew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Staffordshire South

    AI-generated summary

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unclear lone-working procedures for entering patients’ rooms

    Wider context from the report

    “(5) I wonder if there needs to be a review of any lone-working policy or procedure with particular reference as to when to enter patients’ rooms. ”

    Source location

    Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Simon Anthony Graham · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Continuation of lone working during emergencies

    Wider context from the report

    “2. Concern 1: At any one time only one support worker is working. The death of Simon Graham identified a number of concerns arising from lone working during an emergency: A) Upon concern being raised by Simon Graham’s wife, the support worker was prevented from promptly checking on his wellbeing because he was with another resident at the medicine cupboard. He had to finish with the other resident and ensure the medicine cupboard was left secure. This caused a delay of about 10-15 minutes before the support worker could check on Simon Graham. Further delay was then caused by confusion over rooms – see below. B) After forcing entry and finding Simon Graham hanging and in cardiac arrest the support worker got him down and commenced CPR. He had to call for help from other residents but no one came. He had to break-off CPR for at least 80 seconds when he ran down three flights of stairs to answer the door thinking it was an ambulance (it was in fact the deceased’s wife). I heard evidence that the lone working still exists because the current financial contract with the NHS is insufficient to cover the cost of a second support worker, despite Future Care & Social Care Association wanting to end lone working. ”

    Source location

    Simon Anthony Graham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with partners to address recruitment and retention challenges so services are appropriately resourced.

    Verbatim wording from the response

    “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 9 · response
    Published 4 October 2018

    Open published response

  6. East London

    AI-generated summary

    Bernard Aziengbe Ovu · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Bernard Aziengbe Ovu entered a non-public area of Canning Town Station and was later seen falling down emergency exit stairs to the DLR platforms. He was found several hours later and died from a head injury. Concerns included an incorrect assumption that he had left the non-public area, the lack of clear written procedures for lone-working staff, difficulties accessing recorded CCTV, and inconsistent dissemination of policies and procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clear written procedures for lone-working staff responding to likely trespassers

    Wider context from the report

    “The evidence at the Inquest hearing established that there was no clear written procedures to lone working staff on what action should be taken in the event of a likely trespasser in the non-public area, beyond the emergency exit gates. Practice differed from witness to witness as to what should be done in these circumstances. A clear written procedure may assist staff in dealing with these circumstances in the future. ”

    Source location

    Bernard Aziengbe Ovu · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester West

    AI-generated summary

    Javaid Iqbal · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Javaid Iqbal, who was working alone as a security guard at a construction site, died after lighting charcoal in a wheelbarrow inside a portacabin when the generator failed and left him without heat or light. The concerns included inadequate response to his reports, insufficient cold-weather clothing, lack of clear instructions for lone working, and the need for written instructions and training concerning welfare, safe temperatures, clothing, and leaving the site.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide lone night workers with clear instructions for responding to unexpected situations

    Wider context from the report

    “(1) Javaid Iqbal was working alone on the night of the 5th - 6th December 2014. It was very cold that night. The generator supplying heat, (2) Despite reporting this situation to his employer and the relevant control room, he was left to devise a method of keeping warm by himself. (3) Mr Iqbal did not have appropriate clothing to protect him from the cold, even though he was required to make periodic checks outside during the course of the night. (4) As a lone worker at night, Mr Iqbal needed clear instruction as to how to respond to the situation that had unexpectedly arisen. (5) Clear written instructions should be provided by the employer accompanied by suitable training so as to ensure adequate provision is made for the welfare of other lone night security guards both as to i. The personal protective equipment and clothing needed on a cold night when they are expected to work outside ii. The minimum acceptable temperature of the premises they are expected to work in. iii. Their authority to leave site without loss of pay should it prove too cold to work and they are unable to obtain instructions from their employer or controller as to the remedial action to be taken. ”

    Source location

    Javaid Iqbal · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    DAVIN PAUL SHORT · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Davin Paul Short was discovered unresponsive in his prison cell on 4 October 2011 and was pronounced deceased shortly afterwards. The inquest concluded that he died from natural causes, with acute lobar pneumonia recorded as the medical cause of death. Concerns were raised about the lack of guidance for recording medically significant cell-bell calls and ensuring that a lone healthcare worker had a radio to respond to emergencies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure a lone healthcare staff member has a radio

    Wider context from the report

    “(2) I also heard evidence that although there were now adequate radios for all three healthcare staff it was not made clear that if a single member of healthcare were on duty he or she must have a radio. I am therefore concerned that without a specific guidance, there is a risk that a single member of healthcare may not have a radio causing delay in responding to an emergency call and possible risk to life. ”

    Source location

    DAVIN PAUL SHORT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce an expanded radio system and routinely issue radios to all healthcare staff on arrival.

    Verbatim wording from the response

    “In response to your second concern, as you were informed at the inquest, a new radio system with an additional number of radios has been introduced at HMP Wayland since Mr Short's death. All healthcare staff are now routinely issued with radios upon arrival at the prison and this enables them to respond to emergency calls without delay.”

    Source location

    2015-0245-Response-by-NOMS
    Page 2 · response
    Published 29 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce a radio system providing more radios and radios to all Healthcare staff on arrival.

    Verbatim wording from the response

    “In relation to the issue of radios to Healthcare staff, since the death of Mr Short, a new radio system has been introduced with a greater number of radios. All Healthcare staff are issued radio upon arrival as a matter of course and as such, the circumstances discussed as part of the inquiry will not re-occur.”

    Source location

    2015-0245-Response-by-HMP-Weyland
    Page 1 · response
    Published 29 June 2015

    Open published response
Back to top

Data last updated 7 September 2026