Recurring concern

Unsafe work-at-height operations

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First reported 5 Aug 2013•Latest report 8 Mar 2021

Definition

What this concern includes

Includes failures of controls specifically dedicated to safe work at height, including hazard identification, risk assessment, competent planning and supervision, worker training and instruction, suitable equipment, safe methods, monitoring and emergency arrangements.

Not included

  • Excludes generic staff supervision, instruction, training or risk-assessment deficiencies where work at height is not the identified safety concern.
  • Excludes failures involving ladders or other access equipment where no work-at-height safety context is supported; those may belong to a narrower equipment-specific concern.
  • Excludes unrelated working-practice, occupational-health or workplace hazards that do not materially concern work at height.
  • Excludes failures arising after a safe work-at-height operation has been completed, unless they identify a deficient work-at-height control.
Reports
6

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2013–2021

First to latest report issue date

Stated actions
10

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.

Health and Safety Executive2
Blatchington Mill School1
Brighton and Hove City Council1
Carrington Doors Limited1
Driver and Vehicle Standards Agency1
Forestry Commission1
National Rigging Advisory Group (NRAG)1
Professional Lighting and Sound Association Limited1
Road Haulage Association Limited1
The Arboricultural Association1
Unusual Rigging Limited1
Wayne Clarey Roofing & Cladding Limited1

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. Black Country

    AI-generated summary

    Adam Joseph Brunskill · 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

    Adam Joseph Brunskill fell approximately 8 metres through a fragile glass rooflight while working on a warehouse roof and died the following day from a devastating brain injury. Concerns included his lack of prior roofing experience, accredited training and supervision, together with inadequate safety barriers, designated walkways, safety netting, structured training, supervisory arrangements and appraisal systems.

    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 new employees have the required roofing experience, qualification and health and safety training

    Wider context from the report

    “(1) The Coroner heard at inquest that Adam had been employed by Wayne Clarey Roofing and Cladding to work on a roof with no prior experience of working on a roof and no CSCS card nor had he completed a mandatory one-day Health & Safety course; ”

    Source location

    Adam Joseph Brunskill · 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

    Implement a structured Pro-Clad training programme for new and unqualified employees.

    Verbatim wording from the response

    “1. Since the inquest, Wayne Clarey Roofing has been using a clear designated structured training programme for new and/or unqualified employees. It is the Pro-Clad training structure. It was stated at the inquest by ████████ that ████████ is an employee of Pro-Clad as 99% of his work is carried out for Pro-Clad.”

    Source location

    2021-0384-Response-from-Wayne-Clarey-Roofing-Cladding-Ltd_Published
    Page 3 · response
    Published 18 November 2021

    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

    Designate two supervisors to oversee worker training and safety.

    Verbatim wording from the response

    “2. The 2 supervisors are ████████ and ████████. This was confirmed in the inquest by both men.”

    Source location

    2021-0384-Response-from-Wayne-Clarey-Roofing-Cladding-Ltd_Published
    Page 3 · response
    Published 18 November 2021

    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

    Appraise workers daily, recommend further qualifications, and arrange workplace testing by outside agencies.

    Verbatim wording from the response

    “3. ████████ appraises the workers on a daily basis and recommends them for further qualification which is tested by outside agencies whilst they are at work.”

    Source location

    2021-0384-Response-from-Wayne-Clarey-Roofing-Cladding-Ltd_Published
    Page 3 · response
    Published 18 November 2021

    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

    Lack of training was not considered the main cause of the accident; failure to prevent the fall was the material safety issue.

    Verbatim wording from the response

    “It is important to make clear HSE’s view that regardless of his experience or inexperience, Adam Brunskill’s death should have been prevented, not by training, but by the risk assessor recognising the fragile nature of the rooflights during their risk assessment, and by the consequent management of that risk. This could have been by means of avoiding the risk with collective means or personal means, by barriers or coverings, and by netting below to minimise the consequences of a fall through the fragile surfaces. The fall from roof to floor should not have been possible.”

    Source location

    2021-0384-Response-from-Health-Safety-Executive_Published
    Page 3 · response
    Published 18 November 2021

    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

    Existing Principal Contractor training support and training-matrix arrangements, extended to subcontractors, were considered sufficient for identified training needs.

    Verbatim wording from the response

    “In their revised Contract For Services document, Proclad state that they are happy to provide support to subcontractors in facilitating training for workers, and to grant access to their training matrix systems. Wayne Clarey Roofing & Cladding Ltd will use this arrangement.”

    Source location

    2021-0384-Response-from-Health-Safety-Executive_Published
    Page 3 · response
    Published 18 November 2021

    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 Principal Contractor’s training-matrix system, including appraisals and training-needs analysis, was considered sufficient for subcontractors.

    Verbatim wording from the response

    “In their revised Contract For Services document, Proclad state that their training matrix system will be available to subcontractors. As Wayne Clarey Roofing & Cladding Ltd continue to work full time for Proclad, and they fully use their systems, this will include appraisals and training needs analysis.”

    Source location

    2021-0384-Response-from-Health-Safety-Executive_Published
    Page 4 · response
    Published 18 November 2021

    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

    Existing training, supervision and external assessment arrangements are treated as sufficient for future trainees and experienced workers.

    Verbatim wording from the response

    “When questioned about future trainees ████████ stated that he would never put himself in the position of having a new trainee as he could not, in all conscience, take on anyone again because of the accidental death of Adam. Therefore he restricts ourselves to the hypothetical situation of a new trainee skilled being placed on an induction course under supervision. ████████ would insist that any trainee would have to have the mandatory card and undertake the health and safety course. Also, as 99.9% of his work is with Pro-Clad, he would ensure that he would make himself available to use their training and also set out a full training schedule with checks by both himself and Pro-Clad. In relation to new workers with experience, again he would make sure that he adopted the Pro-Clad training structure.”

    Source location

    2021-0384-Response-from-Wayne-Clarey-Roofing-Cladding-Ltd_Published
    Page 1 · response
    Published 18 November 2021

    Open published response
  2. Bedfordshire and Luton

    AI-generated summary

    Russell Paul BOWRY · 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

    Russell Paul Bowry died after falling 11 metres through exposed roof material while working at height on a stage structure at Cardington Studios. The concerns included inadequate planning and supervision of work at height, insufficiently designed fall-protection systems, and unsafe working practices affecting self-employed riggers.

    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 work-at-height systems provide adequate fall protection

    Wider context from the report

    “(b) Employers in your industry may not realise they are responsible for designing the necessary safety features for work at height, including engaging the services of those who have the right skills to design such systems. Safe systems of work include ensuring that all clipping on points and safety features have the necessary impact requirements to hold a falling person and that the work can be done while the riggers are always clipped on or, that it is safe without clipping on; ”

    Source location

    Russell Paul BOWRY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 competent planning and supervision of work at height

    Wider context from the report

    “(a) Employers in your industry may believe that they can safely delegate to individual riggers the responsibility to plan work at height, supervise it and carry it out safely. Russell Bowry was an NRC level 2 rigger but he was working directly under ELP, whose employees had no NRC qualifications. There was no head rigger. ELP gave evidence that it was their expectation that experienced riggers could be relied upon to ensure their own safety. Yet the riggers from whom I heard, told me that they were not always clipped on; ”

    Source location

    Russell Paul BOWRY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 riggers remain clipped on during work at height

    Wider context from the report

    “(a) Employers in your industry may believe that they can safely delegate to individual riggers the responsibility to plan work at height, supervise it and carry it out safely. Russell Bowry was an NRC level 2 rigger but he was working directly under ELP, whose employees had no NRC qualifications. There was no head rigger. ELP gave evidence that it was their expectation that experienced riggers could be relied upon to ensure their own safety. Yet the riggers from whom I heard, told me that they were not always clipped on; ”

    Source location

    Russell Paul BOWRY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 competent design of necessary work-at-height safety features

    Wider context from the report

    “(b) Employers in your industry may not realise they are responsible for designing the necessary safety features for work at height, including engaging the services of those who have the right skills to design such systems. Safe systems of work include ensuring that all clipping on points and safety features have the necessary impact requirements to hold a falling person and that the work can be done while the riggers are always clipped on or, that it is safe without clipping on; ”

    Source location

    Russell Paul BOWRY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  3. Gloucestershire

    AI-generated summary

    Christopher George Barnes · 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

    Christopher George Barnes, a 69-year-old lorry driver, fell approximately 2.3 metres from the load on his lorry while attempting to untangle securing straps and died from his injuries on 24 April 2018. The principal concern was whether consignors, consignees and their employees sufficiently understood the hazards of working at height on vehicles or trailers and had appropriate safety measures and controls in place.

    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 an appropriate level of safety and maintain sufficient control measures for working at height on vehicles or vehicle trailers

    Wider context from the report

    “Whether consigness and consigners and their employees have sufficient understanding of the hazards and risks associated with working at height on a vehicle or vehicle trailer, and whether they ensure an appropriate level of safety and have in place sufficient control measures to satisfy their legal obligations. ”

    Source location

    Christopher George Barnes · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 sufficient understanding of working-at-height hazards and risks on vehicles or vehicle trailers

    Wider context from the report

    “Whether consigness and consigners and their employees have sufficient understanding of the hazards and risks associated with working at height on a vehicle or vehicle trailer, and whether they ensure an appropriate level of safety and have in place sufficient control measures to satisfy their legal obligations. ”

    Source location

    Christopher George Barnes · 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

    Continue drafting guidance on the safe use of tail-lifts with the Health and Safety Executive.

    Verbatim wording from the response

    “The RHA is itself currently engaged with the HSE in drafting guidance with regard to the use of tail-lifts on behalf of the RHA, its members and other trade associations. This is however a costly and very time-consuming exercise (we are currently 3 years into this project) and further work is not something that we can do lightly or easily which may use a disproportionate amount of our members funds.”

    Source location

    2019-0164-Response-by-RHA
    Page 1 · response
    Published 29 July 2019

    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

    Raise the coroner’s concerns and explore wider dissemination of relevant vehicle-load safety guidance to operators at the next forum meeting.

    Verbatim wording from the response

    “It is true that traffic commissioners seek to work with other agencies to ensure that shared concerns regarding the safe operation of vehicles are more widely communicated. Through contacts such as the Vehicle Safety Compliance Forum, chaired by DfT, we continue to liaise with HSE. The next meeting is on 5th June, I will ask my colleague, ████████ who represents traffic commissioners at that meeting and is commissioner for the traffic area in which your coronial district lies, to raise your concerns and to explore how that guidance might be drawn to the attention of operators more widely. I envisage that is also your purpose in seeking the involvement of The Road Haulage Association. If I have misunderstood the intent of your report, then I would be happy to discuss the issues in more detail with you.”

    Source location

    2019-0164-Response-Senior-Traffic-Commissioner-for-Great-Britain
    Page 2 · response
    Published 29 July 2019

    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 incident appears unconnected with the specific operator’s licence requirements, which concern satisfactory arrangements to prevent vehicle overloading.

    Verbatim wording from the response

    “From your report I can infer that the operator in question holds a goods vehicle operator’s licence. The requirements for that licence include section 13C of The Goods Vehicle (Licensing of Operators) Act 1995. Section 13C(3) requires only that there be satisfactory arrangements for securing that vehicles used under the licence are not overloaded.”

    Source location

    2019-0164-Response-Senior-Traffic-Commissioner-for-Great-Britain
    Page 1 · response
    Published 29 July 2019

    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

    Traffic commissioners lack investigative powers and resources to undertake the responsive investigation.

    Verbatim wording from the response

    “Traffic commissioners are not provided with investigative powers or resources. However, a conviction for breaches of the above duties might be relevant to the consideration of an operator’s ability to hold an operator’s licence. I regret that I do not have formal powers in the way suggested in your Report as responsibility for enforcing that legislation lies with the Health and Safety Executive.”

    Source location

    2019-0164-Response-Senior-Traffic-Commissioner-for-Great-Britain
    Page 1 · response
    Published 29 July 2019

    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

    Responsibility for enforcing safe-working legislation lies with the Health and Safety Executive, not the traffic commissioners.

    Verbatim wording from the response

    “Your report at item 4 refers to circumstances where Mr Barnes was involved in the unloading of a vehicle. Mr Barnes climbed onto the palletised load and, whilst attempting to untangle the straps which were used to secure the load, he took a step back and fell from the load on the vehicle. This would appear unconnected with the specific terms of the operator’s licence. As you will be aware, the duties to establish safe systems of work are set out in The Management of Health and Safety at Work Regulations 1999 and The Work at Height Regulations 2005 and by reference to general duties under the Health and Safety at Work etc. Act 1974.”

    Source location

    2019-0164-Response-Senior-Traffic-Commissioner-for-Great-Britain
    Page 1 · response
    Published 29 July 2019

    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 trade association lacks a specific mandate to draft or distribute members’ health and safety obligation policies.

    Verbatim wording from the response

    “We at the RHA are a trade association who have strong links with the industry and do represent a significant proportion of the industry, however, as a trade association we do not have a specific mandate with which we can draft or distribute policy documents regarding a members Health and Safety at Work Act obligations.”

    Source location

    2019-0164-Response-by-RHA
    Page 1 · response
    Published 29 July 2019

    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 Health and Safety Executive should lead or be involved in drafting relevant transport health and safety policies, advice or guidance.

    Verbatim wording from the response

    “Furthermore, we suggest that the most appropriate organisation to whom the Coroner could write with such a request is the Health and Safety Executive (HSE). The HSE have a team who we understand deal specifically with transport and large vehicle fleet operators and as such we believe that they would be interested in and, in order for it to be effective, should be involved with the drafting of any health and safety policies, advice or guidance going forward.”

    Source location

    2019-0164-Response-by-RHA
    Page 1 · response
    Published 29 July 2019

    Open published response
  4. 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 of health and safety assessment templates and audits to address work at height

    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

    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 working-at-height training

    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
  5. Manchester South

    AI-generated summary

    Paul Anthony Daniels · 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

    Paul Anthony Daniels died after falling approximately 50 feet from a conifer tree while working as a tree surgeon at Hazel Grove Golf Club. Concerns included the staffing ratio, the groundsman’s lack of aerial-work qualification, and difficult communication between the groundsman and tree surgeons.

    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 an aerial-work-qualified groundsman for tree surgeons

    Wider context from the report

    “2. The groundsman supporting the tree surgeons was not qualified for aerial work. This meant that should the tree surgeon have required assistance whilst in the trees the groundsman could not have gone to their help; ”

    Source location

    Paul Anthony Daniels · 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

    Promulgate incident learning and reinforce adherence to relevant tree-work safety guidance through AFAG committee members and their organisations.

    Verbatim wording from the response

    “AFAG next meets as a committee on 8 May 2018 and I will take this opportunity to promulgate the key learning points from this incident via the committee members. The range of organisations represented on the committee should enable the message, through their respective memberships, to have a wide reach throughout the industry. I will ask that members underline the importance of all people involved in this type of work adhering to the standards set out in the guidance and highlight the concerns raised in your letter.”

    Source location

    2018-0003-Response-by-HSE
    Page 2 · response
    Published 7 March 2018

    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

    Ensure lessons from the incident are considered when AFAG 401 and AFAG 402 are next reviewed.

    Verbatim wording from the response

    “In addition as a matter of routine AFAG and its members keep guidance under review to ensure that lessons learned through incidents are reflected in the guidance and we will ensure that these points are again considered when these specific leaflets are next reviewed.”

    Source location

    2018-0003-Response-by-HSE
    Page 2 · response
    Published 7 March 2018

    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 emergency procedures with in-house arborists against AFAG guidance 401 and 402.

    Verbatim wording from the response

    “• Reviewing the emergency procedures against AFAG guidance 401 & 402 with our in-house arborists;”

    Source location

    2018-0003-Response-by-Forestry-Commission
    Page 1 · response
    Published 7 March 2018

    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

    Re-brief employees supervising arboricultural contracts on key AFAG guidance requirements.

    Verbatim wording from the response

    “• Re-briefing employees, who supervise arboricultural contracts, on the key requirements of this guidance;”

    Source location

    2018-0003-Response-by-Forestry-Commission
    Page 1 · response
    Published 7 March 2018

    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

    Continue rigorously implementing emergency-rescue requirements in areas under Forestry Commission control.

    Verbatim wording from the response

    “I would also like to confirm the AFAG guidance and current best practice requires a risk assessment to be carried out to establish the emergency procedures, methods of communications and sufficient competent resources to effect a rescue without delay.”

    Source location

    2018-0003-Response-by-Forestry-Commission
    Page 2 · response
    Published 7 March 2018

    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 absence of evidence about compliance with supervision, auditing and proficiency requirements prevents further comment on those measures.

    Verbatim wording from the response

    “Reducing the risk of future deaths from human error in this respect revolves around supervision, auditing and the measurement of operator proficiency.”

    Source location

    2018-0003-Response-by-Arboricultural-Assocation_Redacted
    Page 1 · response
    Published 7 March 2018

    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

    Existing AFAG guidance adequately addresses tree-climber ratios, aerial-rescue training and communication requirements for legal compliance.

    Verbatim wording from the response

    “These three matters are addressed in long standing guidance produced by AFAG and effectively set out the standards expected to ensure legal compliance in this type of work.”

    Source location

    2018-0003-Response-by-HSE
    Page 1 · response
    Published 7 March 2018

    Open published response
  6. North Wales (East and Central)

    AI-generated summary

    ALAN SMITH · 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

    ALAN SMITH died after falling from a ladder that moved while he was repairing a factory door, sustaining a severe head injury. A witness reported that he had not received specific training for working at height and that generic risk assessments and method statements were not routinely used by employees.

    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 specific working-at-height training

    Wider context from the report

    “A witness and co-worker of the Deceased indicated that he had had not received any specific training regarding working at height during the time of his employment at Carrington Doors and indicated that although generic Risk Assessment forms and Method Statements were available, these were not used routinely by employees. ”

    Source location

    ALAN SMITH · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026