Recurring concern

Unclear accountability for health and safety controls

First to latest report 20 Dec 2013 — 28 May 2025

Reports that mention this concern
17
Times this concern has been raised
18
Stated actions linked to this concern
28

What this concern includes

Includes failures to assign, communicate, maintain or exercise clear accountability for health and safety controls across strategic, operational and property or service-level functions, where unclear ownership can leave safety risks unmanaged.

What is not included
  • Excludes failures limited to a specific risk assessment, inspection, maintenance task or remedial action when accountability for the wider health and safety control arrangement is not deficient.
  • Excludes generic organisational governance, leadership or responsibility concerns with no direct health and safety control or safety consequence.
  • Excludes ordinary disagreements about responsibility where a clear accountable owner exists and the control is operating reliably.

Reports and published responses 17 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Northamptonshire

    AI-generated summary

    David Chandler · 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 Chandler died at the scene on 9 November 2016 during work to remove a dormant compressor at the Carlsberg Brewery, following a high-pressure escape of gaseous ammonia. The concerns included reliance on an isolation from earlier work, inadequate review of the isolation standard, unclear responsibilities between organisations, and an incorrectly completed Permit To Work that did not refer to hazardous substances.

    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 establish clear responsibility for ensuring compressor isolation

    Wider context from the report

    “(1) The isolation for the 2014 work was still in place and does not appear to have been reviewed in the intervening period. The 2014 work was of a different nature and did not require physical removal of the whole compressor. There does not appear to have been any formal review of the appropriate isolation standard for the work in November 2016 to be performed safely. (2) Carlsberg contracted the work to Crowley Carbon who employed specialist refrigeration engineers. The evidence at the inquest suggested that Crowley Carbon and Carlsberg were each relying on the other to ensure that the compressor was safely isolated. (3) The Permit To Work (PTW) issued by Carlsberg to allow Speedrite to remove the compressor made reference to the 2014 PTW isolation, was completed incorrectly, and made no reference to hazardous substances. (4) Relying on the isolation from previous work on the compressor appears to have caused confusion as to the safe level of isolation necessary for work of a different nature two years later. ”

    Source location

    David Chandler · 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

    Enhance project pre-construction information so hazards and isolation responsibilities are identified, and require assigned parties to acknowledge them through a client brief checklist.

    Verbatim wording from the response

    “Since the incident, Carlsberg has enhanced its suite of documentation concerning the provision of pre-construction information to relevant parties. This documentation was and is specific to each project and will identify the hazards relevant to the works being undertaken. As part of this communication the responsibility for isolations is clearly defined. To ensure all parties understand the role that they are assigned specific to CDM15 Carlsberg continues to require those parties to sign a “client brief checklist”.”

    Source location

    2018-0215-Response-by-Carlsberg-UK
    Page 2 · response
    Published 14 August 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

    Crowley Carbon, as Principal Contractor and Principal Designer, was responsible for planning and controlling isolation risks during the works.

    Verbatim wording from the response

    “During the course of 2016 Crowley Carbon Limited (Crowley Carbon), a specialist energy efficiency company with expertise in industrial ammonia refrigeration plant systems, conducted an energy efficiency study and concluded that Carlsberg could make significant improvements. Carlsberg accepted Crowley Carbon's recommendations and appointed them as Principal Contractor and Principal Designer (within the meaning of the Construction Design and Management Regulations 2015) for the project.”

    Source location

    2018-0215-Response-by-Carlsberg-UK
    Page 1 · response
    Published 14 August 2018

    Open published response

  2. South Wales Central

    AI-generated summary

    Lesley Hanson · 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

    Lesley Hanson, who had severe learning disabilities and poor stability, gained access to stairs at her supported accommodation on 11 March 2017 and fell, sustaining injuries that led to her death. The concerns were that care and risk assessments did not address the gate being left open, the type of stair-gate or locking mechanism, and that responsibility for environmental safety controls was unclear. The inquest jury found the arrangements inadequate, including failure to follow the service plan and repeated occasions when the stair-gate had been left open.

    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 responsibility for the environment and resident safety control measures

    Wider context from the report

    “(2) It was unclear from the evidence who had the responsibility for the environment and control measures to ensure residents safety at the property. ”

    Source location

    Lesley Hanson · 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 and maintain an agreed referral pathway clarifying responsibilities for environmental-control assessments, including joint occupational-therapy assessment of stairgate requests.

    Verbatim wording from the response

    “1.3 Where assessments for environmental controls are required, the Senior Support Worker (or delegated member of staff) will complete a referral form and forward to ABMU Learning Disability Health Team or the Cardiff Communities Occupational Therapy Team (CCOT) depending on the nature/size of the work requested. A ‘Referral Pathway’ flowchart has been designed to ensure consistency of process. This flowchart has been subject to consultation with the ISL Manager Supported Living Coordinator, Learning Disability Social Services Team Managers, ABMU Health Team Manager and Cardiff Occupational Therapists.”

    Source location

    2017-0303-Response
    Page 2 · response
    Published 27 November 2017

    Open published response

  3. South Wales Central

    AI-generated summary

    Ashley Daniel Talbot · 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

    Ashley Daniel Talbot, a 15-year-old pupil, was struck by a school minibus shortly after 3pm on 10 December 2014 while running to catch his bus and died at the scene. The concerns identified deficiencies in the school service road and bus bay, inadequate staff supervision, unreported near misses, and a lack of accountability among stakeholders involved in the school’s design and construction.

    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 accountability among stakeholders for safe school premises design and construction

    Wider context from the report

    “(3) The wider investigation revealed that there was a clear lack of accountability between the various stakeholders in the design and construction of the school premises to ensure that a safe facility was constructed. Appropriate Safety Advice at an early stage, the evidence showed, would have reduced the likelihood of injury or death. ”

    Source location

    Ashley Daniel Talbot · 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

    Establish multidisciplinary design boards and integrate traffic safety, highway and infrastructure-cost considerations into new-school projects.

    Verbatim wording from the response

    “The design project board for any new school build is now a multi-discipline team including designers, clients, highways road safety staff and health and safety officers. The project is now planned more strategically and with a holistic view. Early consideration is given to traffic management arrangements both internal and external for any new schools. Advice is sought at an options appraisal stage to ensure any potential highway issues are identified prior to a site being chosen. Infrastructure costs, including works to highways and on-site parking/drop-off arrangements, are now included in the overall costs of the budget. Once a site is identified and design is underway, the project board maintains a link with the on-site management of the build.”

    Source location

    Ashley-Talbot-Response
    Page 2 · response
    Published 5 March 2017

    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

    School governors had no authority or input regarding the facility’s design or construction.

    Verbatim wording from the response

    “(3) While I agree with the lack of accountability regarding the construction of a safe facility school governors would have had no input regarding the design or construction.”

    Source location

    2017-0051-Response-by-Maesteg-School
    Page 1 · response
    Published 5 March 2017

    Open published response

  4. Warwickshire

    AI-generated summary

    Mark Richard Seward · 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

    Mark Richard Seward died after a pressurised cylinder fractured during workplace testing, ejecting debris that caused a serious head injury. Concerns included unclear definitions of pressure testing and questioned compliance with PUWER and HSE guidance, with evidence that poor practices were replicated elsewhere in the industry.

    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 strategic and operational responsibility for health and safety issues

    Wider context from the report

    “(1) It was unclear who had responsibility for Health and Safety issues at AGD at a strategic (ie. Board) level and operationally. ”

    Source location

    Mark Richard Seward · 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

    Remind all staff about the health and safety policy and where to access it.

    Verbatim wording from the response

    “1. The company has a health and safety policy setting out the roles and responsibilities for all personnel including directors, managers and employees. A copy of this policy is available both electronically on the computer and in a hard copy kept in the office, which is accessible to all employees. A further copy of the policy is displayed on the health and safety notice board by the canteen and another copy is on display in the office reception area.”

    Source location

    SEWARD-Response
    Page 1 · response
    Published 5 April 2016

    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 site safety induction with specialist advice and provide refresher training on safety roles and hierarchy.

    Verbatim wording from the response

    “2. AGD continue to use the Site Safety PowerPoint induction given to all staff before they start work. Following the Inquest, AGD have reviewed the induction with specialist advice from the company’s health and safety consultants. The induction details the key health and safety positions at the company and explains the health and safety hierarchy. All staff are being given refresher training on these elements.”

    Source location

    SEWARD-Response
    Page 1 · response
    Published 5 April 2016

    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

    Develop a communications strategy explaining the safety management system, its rules and staff responsibilities.

    Verbatim wording from the response

    “(3) the arrangements in place to ensure all staff are skilled, trained and competent for the work they undertake; and (4) to ensure the monitoring arrangements are adequate and properly undertaken. Hand in hand with this review is a new communications strategy to ensure all staff are aware of the system, its rules and their own responsibilities.”

    Source location

    SEWARD-Response
    Page 3 · response
    Published 5 April 2016

    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

    Appoint a Safety Officer/Assistant Manager with operational workshop safety experience.

    Verbatim wording from the response

    “7. AGD have appointed a new Safety Officer/Assistant Manager with substantial experience in operational workshop health and safety. This new role has been recruited to ensure that working practices are up-to-date with current legislation and industry best practice. To compliment this new role, the company has altered the Paint Shop Supervisor role to the wider role of Workshops Supervisor so that the new Safety Officer/Assistant Manager can concentrate on ensuring all health and safety rules, controls and best practices are understood and fully implemented throughout the operational site for all employees and visiting suppliers.”

    Source location

    SEWARD-Response
    Page 3 · response
    Published 5 April 2016

    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

    Expand the Paint Shop Supervisor role to Workshops Supervisor to support implementation of site-wide safety rules and controls.

    Verbatim wording from the response

    “7. AGD have appointed a new Safety Officer/Assistant Manager with substantial experience in operational workshop health and safety. This new role has been recruited to ensure that working practices are up-to-date with current legislation and industry best practice. To compliment this new role, the company has altered the Paint Shop Supervisor role to the wider role of Workshops Supervisor so that the new Safety Officer/Assistant Manager can concentrate on ensuring all health and safety rules, controls and best practices are understood and fully implemented throughout the operational site for all employees and visiting suppliers.”

    Source location

    SEWARD-Response
    Page 3 · response
    Published 5 April 2016

    Open published response

  5. West Yorkshire (East)

    AI-generated summary

    Christianne Shepherd and Robert Shepherd · 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

    Christianne and Robert Shepherd died from carbon monoxide poisoning while staying with their family in holiday accommodation on Corfu in October 2006. The report identified a badly installed and maintained LPG water heater, disconnected safety devices, defective building and piping, and concerns about inadequate tour-operator and hotel health and safety checks. It also raised wider concerns about carbon monoxide safety standards and information for holidaymakers.

    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

    Delegation of health and safety checks to inexperienced and overworked Tour Representatives

    Wider context from the report

    “4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety. Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed. ”

    Source location

    Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. West Sussex

    AI-generated summary

    Natasha Raghoo · 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

    Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

    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 responsibility for stopping physical observations

    Wider context from the report

    “2. Physical observations of blood pressure, pulse and temperature were sporadic and few in number. This was cause for concern as Natasha had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action. ”

    Source location

    Natasha Raghoo · 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

    Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.

    Verbatim wording from the response

    “Lessons Learned and changes made”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 6 · response
    Published 6 March 2014

    Open published response

  7. Inner South London

    AI-generated summary

    Adrian Johnson · 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

    Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.

    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 responsibility for tobacco-withdrawal screening and management

    Wider context from the report

    “(1) Expert opinion has been given that the failure to routinely screen for and enquire into tobacco withdrawal as part of prison reception screening creates risks to the lives of a small number of vulnerable prisoners. Withdrawal problems may be interpreted by staff as behaviour designed to gain benefits, unless an appropriate health care assessment is conducted. Health care staff at HMP Belmarsh do not appear to be trained to conduct such screening, nor manage withdrawal, nor is it clear whose responsibility it would be. (2) To questioning about steps that HMP had taken to reduce future risks, a governor reported a significant improvement in the conduct of ACCT reviews and pleasing spot checks. However she could not confirm whether there had been any individual learning by those involved. It was not clear that there would be any better consistency of case management in prisoners who move to the Segregation Unit, nor in the way in which members were asked to attend, nor the adequacy of caremap planning. The discipline staff appeared to blame the health care staff for the incomplete health care information at reviews, but there was no indication that they accepted that the case manager and chair had responsibilities to secure the information if it was not volunteered. It remained unclear how decisions on reduction of observations would in future be fully informed in exceptional cases where vulnerable prisoners are in the Segregation Unit. Improvements in the processes and conduct of ACCT reviews may not have fully addressed the areas of concern, which create significant risks for vulnerable prisoners ”

    Source location

    Adrian Johnson · Prevention of Future Deaths report
    Page 4 · 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

    Develop a care pathway with healthcare partners to screen for tobacco-withdrawal risks and provide appropriate support, including nicotine replacement therapy.

    Verbatim wording from the response

    “NOMS accepts that despite the above range of screening during the reception process, further consideration needs to be given to identifying prisoners for whom tobacco withdrawal may give rise to an increase in suicidal feelings or self-harm, and to develop the support given to prisoners who do not have access to tobacco, or to the amount they would normally rely on. NOMS is currently working with healthcare partners to develop a care pathway, that includes an appropriate level of screening, to ensure that when tobacco is not available, or it is available but in more limited supply than the level they are used to (because they have limited funds/access to prison shop), that the relevant healthcare provider ensures that appropriate support, including Nicotine Replacement Therapy is available.”

    Source location

    2013-0364-Response-by-NOMS
    Page 2 · response
    Published 20 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026