Recurring concern

Failure to assess underlying process risks independently of existing controls

First to latest report 6 Jan 2014 — 29 Sep 2023

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures in formal process or operational risk assessments to identify and assess the underlying hazard, likelihood and impact before relying on existing mitigating controls, including failure to reflect the actual conditions of work or operation.

What is not included
  • Excludes failures limited to communicating, disseminating or explaining an otherwise accurate risk assessment where the assessment itself is not deficient.
  • Excludes failures to implement mitigation measures after the underlying risk has been properly assessed.
  • Excludes hazard-specific, pathway-specific or beneficiary-specific risk-assessment systems where that named concern provides the more specific supported boundary.
  • Excludes generic staffing, training, documentation or governance deficiencies unless they directly cause failure to assess the underlying process risk.

Reports and published responses 5 reports

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

  1. Derby and Derbyshire

    AI-generated summary

    John Frederick WRIGLEY · 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

    John Wrigley died after his kart left the track during a qualifying session on 3 May 2021, crossed wet grass and struck a lorry tyre wall at high speed. The report raised concerns that additional energy-absorbing protection was available but not used, and that insufficient regard was given to wet grass and wet-weather risks when deciding whether racing should proceed.

    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 adequately assess and provide additional energy-dissipating protection in front of the tyre barrier

    Wider context from the report

    “1. The lorry tyre boundary wall remained in position on impact, moving only a few millimetres backwards; it did not absorb enough energy to slow the velocity of the kart. The lorry tyre barrier did dissipate energy; evidence provided by those investigating the circumstances indicated that the primary function of the tyre barrier is to protect what lies outside the track e.g spectators and to contain the vehicle within the confines of the track. Energy dissipating or impact absorbing protection such as Airfence/Recticel - a closed cell barrier - was available to be placed in front of the tyre barrier but was not utilised ; the view was that shallow angle contact with a closed cell foam barrier would result in ‘pocketing’ i.e. cause injury rather than mitigate a head injury. Super karts are not fitted with safety belts. This aspect, racer error and an inability to control the kart following such an error and loss of control was not taken into account when decisions were made regarding the placement of additional impact absorbing protection. Urgent action is required to review what additional type of energy dissipating or impact absorbing protection (e.g Airfence/Recticel) should be placed in front of the tyre barrier, where and in which circumstances. All risks, no matter how minimal, should be taken into account. Additional protection was available but not used. It may have reduced the potential severity of such an incident and prevented the death of a competitor or racer. ”

    Source location

    John Frederick WRIGLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 barrier placement was appropriate, and Recticel-type barriers are unsuitable on straights because of pocketing risks.

    Verbatim wording from the response

    “5. All circuits Licenced for Regulated motor sport by the Statutorily recognised authorised bodies - Motorsport UK and the AutoCycle Union (“ACU”) in this case - rigorously apply the application of and requirement for appropriate barriers to be positioned at relevant locations and the types of which depend on the various track features (simply expressed as straights or corners).”

    Source location

    Response from Motorsport UK Association Limited
    Page 2 · response
    Published 5 October 2023

    Open published response

  2. Surrey

    AI-generated summary

    Henry Edward Hullin Doll · 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

    Henry Edward Hullin Doll, who had a learning disability, Down’s Syndrome and dementia and was at high risk of aspiration and choking, entered the kitchen of his residential care home alone on 21 February 2021, obtained a shortbread biscuit, choked and aspirated on it, and died the following day from aspiration pneumonia. The court found that the risks of him obtaining unsuitable food and eating it unsupervised had not been identified or appropriately prevented. Concerns also related to the way risk assessments were completed and the effectiveness of staff CPR 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

    Failure to assess risks before considering mitigating measures

    Wider context from the report

    “1. Both the Kenilworth Home Manager and the Regional Director, responsible for some 50 homes, maintained at the inquest that Mr Doll’s risk assessment had been accurately completed and that the appropriate way to conduct a risk assessment was to first consider what mitigating measures were in place and then to go on to assess the likelihood of the risk occurring and the likely impact on the individual. Accordingly, the Coroner is concerned that the risk screening in respect of other residents at Kenilworth, but also other Avenues Group locations, may have been completed in a similar manner. ”

    Source location

    Henry Edward Hullin Doll · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  3. West Yorkshire (Western)

    AI-generated summary

    Isaac John Walter Brocklehurst · 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

    Isaac was playing on a ride-on plastic bike when he travelled through a gap in a low brick wall and into the path of a Scania tipper lorry, sustaining fatal injuries. The report raised a concern about the safety of existing pedestrian gaps in the perimeter wall, as children played in the communal grassed area.

    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 assess the safety of pedestrian gaps in the perimeter wall for children

    Wider context from the report

    “The Inquest heard evidence to suggest that children play within the communal grassed area at the rear of ████████ The Integrity of the low perimeter wall or it's maintenance was not brought into question. • To review the existing pedestrian gaps in the perimeter wall in order to assess the safety aspects for children. ”

    Source location

    Isaac John Walter Brocklehurst · 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

    Continue assessing accommodation type and proximity to risk when reviewing and prioritising neighbourhood works.

    Verbatim wording from the response

    “As part of an investment in our neighbourhoods, Incommunities commenced a Decent Neighbourhoods programme in 2015 which focuses on environmental improvements including fencing to communal areas. When reviewing works to be undertaken, and their prioritisation, we will continue to assess the type of accommodation i.e. family accommodation and proximity to risk. However, some of our communal areas are ‘open plan’ and have been so since their build date and may remain so.”

    Source location

    2016-0486-Response-by-Incommunities
    Page 1 · response
    Published 12 March 2017

    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

    Fit gates within the low perimeter wall at Valley Road.

    Verbatim wording from the response

    “With specific relation to Valley Road and the perimeter wall, gates have been fitted within the low perimeter wall.”

    Source location

    2016-0486-Response-by-Incommunities
    Page 1 · response
    Published 12 March 2017

    Open published response

  4. Essex

    AI-generated summary

    Josephine Foday and Komba Kpakiwa · 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

    Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

    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 assess the pool profile and specific risk factors

    Wider context from the report

    “2) The pool profile, including depths and gradients were not considered when carrying out the hazard identification that is required in the swimming pool guidance document HSG 179 3) The risk assessments did not cover the accurate profile information and any other specific risk factors ”

    Source location

    Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 swimming pool is closed, so no one else will be exposed to a similar risk at that facility.

    Verbatim wording from the response

    “We understand that the swimming pool concerned is now closed and so no-one else will be put at similar risk in this facility.”

    Source location

    2014-0301-Response-by-IOSH
    Page 1 · response
    Published 23 May 2014

    Open published response

  5. North and West Cumbria

    AI-generated summary

    Martin Geoffrey McGlasson · 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

    Martin Geoffrey McGlasson, a plant operative, died at the scene on 2 September 2011 after a nearly three-tonne concrete staircase he was slurrying fell onto and crushed him. The principal concerns were the unsupported method of working, debris and incorrect batten placement potentially causing instability, and a mismatch between the method used on the shop floor and the arrangements described in risk assessments. The report also identified that similar methods were widespread and that inexpensive safer alternatives were available.

    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 risk assessments to reflect work carried out in practice

    Wider context from the report

    “(5) Care should be taken to ensure that Risk Assessments or their contents are disseminated or explained to the staff actually operating the process to ensure that what is being done on the ground is reflected in the Risk Assessment, and proper care given to them assess the actual risk. ”

    Source location

    Martin Geoffrey McGlasson · Prevention of Future Deaths report
    Page 3 · 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

    Revise the risk assessment and draw up amended working procedures for supporting and turning precast stair units.

    Verbatim wording from the response

    “As a result of the death of Mr McGlasson and in light of the particular and unprecedented circumstance of the incident, other measures have also been taken, which include:”

    Source location

    2014-0001-Response-by-DWF
    Page 4 · response
    Published 6 January 2014

    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

    Deliver toolbox talks, issue revised safety documents, consult operatives and supervisors, and adopt an agreed safe system for precast-stair manufacture.

    Verbatim wording from the response

    “6. A series of further TOOLBOX TALKS were also held involving all those concerned in the Management, Supervision & Manufacture of Precast Concrete Stairs reflecting the revised Risk Assessment & Safe Working Method and a copy of these documents were issued to all those noted above. Subsequent to issue to all general operatives and supervisors in the stair department, further consultation took place resulting in adoption of an agreed safe system of work in the manufacturing process of precast stairs, from mould preparation to completion.”

    Source location

    2014-0001-Response-by-DWF
    Page 4 · response
    Published 6 January 2014

    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