Recurring concern

Failure to assess risks before introducing new work procedures

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First reported 3 Nov 2015•Latest report 12 Feb 2025

Definition

What this concern includes

Includes failures to carry out, document or maintain a suitable risk assessment before introducing new work, tasks or procedures, including the anchor's new work and the separate new cleaning procedure assertion.

Not included

  • Excludes risk-assessment failures concerning established work where introduction of new work or a new procedure is not material.
  • Excludes generic training, competence, documentation or policy deficiencies unless they directly constitute or prevent risk assessment before introducing new work.
  • Excludes risk assessments for new equipment, new residents, new providers or other objects unless the report explicitly supports the same new-work or new-procedure introduction concern.
  • Excludes the underlying hazard or unsafe work practice when no failure to assess risks before introducing new work or a procedure is identified.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
4

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.

Maurice Mason Limited1
Ward Bros (Malton) Limited1
Wayland Farms 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. Teesside and Hartlepool

    AI-generated summary

    Gary Lee JAMES · 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

    Gary Lee James died at James Cook University Hospital on 11 January 2019 from injuries sustained when metal frames fell on him while he was trying to move them at Ward Bros. The report identified concerns including inadequate risk assessment, training, equipment, supervision and first-aid provision, as well as failures to address employees’ safety concerns and unsafe working conditions.

    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 risk assessment for new work

    Wider context from the report

    “1. No risk assessment and subsequent safer working practice document in respect of new work undertaken. ”

    Source location

    Gary Lee JAMES · 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

    Reviewed health and safety procedures and implemented improved risk assessments and safe systems of work across all activities.

    Verbatim wording from the response

    “On the wider subject of Ward Bros general health and safety procedures, risk assessments and safe systems of work were in place for all other activities. These had been drafted with the assistance of third parties with the appropriate expertise. Following the accident involving Mr James, Ward Bros conducted a full review of the existing health and safety procedures, in conjunction with third party experts. This resulted in improved risk assessments and systems of work which are reviewed on an annual basis. A training programme is in place which ensures employees receive regular training on the safe systems of work and updates are provided by way of toolbox talks and safety notices.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    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

    Ceasing devanning means there is no ongoing risk of deaths from employees or others undertaking that process.

    Verbatim wording from the response

    “No further devanning has been undertaken by Ward Bros since the accident involving Gary James and we have no plans to become engaged in the process again in the future. For this reason, there is no risk of future deaths occurring at Ward Bros as a result of employees, or anyone else, devanning shipping containers.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    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 and improved risk assessments, safe systems of work, training and expert support address safety concerns for other activities.

    Verbatim wording from the response

    “On the wider subject of Ward Bros general health and safety procedures, risk assessments and safe systems of work were in place for all other activities. These had been drafted with the assistance of third parties with the appropriate expertise. Following the accident involving Mr James, Ward Bros conducted a full review of the existing health and safety procedures, in conjunction with third party experts. This resulted in improved risk assessments and systems of work which are reviewed on an annual basis. A training programme is in place which ensures employees receive regular training on the safe systems of work and updates are provided by way of toolbox talks and safety notices.”

    Source location

    Response from Ward Bros (Malton) Ltd
    Page 1 · response
    Published 14 February 2025

    Open published response
  2. Norfolk

    AI-generated summary

    ARTHUR CAXTON MASON · 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

    On 9 July 2014, Arthur Caxton Mason, aged 21, died after being buried beneath moving grain while cleaning inside a grain bin at Hall Farm. The principal concerns were inadequate staff training in risk assessment, failure to recognise hazards in grain-bin cleaning procedures, and the absence of an emergency plan for hazardous areas on the farm.

    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 risk assessment is in place for the new cleaning procedure

    Wider context from the report

    “(2) It was unclear from the evidence that staff involved in carrying out Risk Assessments recognised the risks of carrying out various tasks on the farm. The current document "Procedure for Cleaning out Grain Bins" does not recognise any risks or hazards in carrying out the tasks and it was not clear from the evidence a Risk Assessment is in place for this new procedure, introduced following and as a result of Mr Mason’s death. ”

    Source location

    ARTHUR CAXTON MASON · 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

    Complete and update the grain-store risk assessment and method statement for the revised cleaning method.

    Verbatim wording from the response

    “With regards to the specific grain store building, a new risk assessment has been done along with a method statement. It is now more detailed and addresses the risks of the new method of work. A copy is attached. This now addresses the risks that are present in the new cleaning method and the appropriate method of work for cleaning the bins. This document was updated as a result of a visit from the HSE, after the Inquest. A version of this updated document will also be sent independently to the HSE and it will also be subject to further review by Cope Safety Management Ltd (see below).”

    Source location

    2016-0128-Response-by-Maurice-Mason-Ltd
    Page 2 · response
    Published 1 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

    Commission CSML to review and amend health-and-safety policies, risk assessments, safe systems, emergency plans and the employee handbook.

    Verbatim wording from the response

    “In order to address the Coroner’s concerns and to address safety issues across MML, the Company has instructed Cope Safety Management Ltd (CSML) (qualifications attached) to review and amend:-”

    Source location

    2016-0128-Response-by-Maurice-Mason-Ltd
    Page 2 · response
    Published 1 April 2016

    Open published response
  3. Norfolk

    AI-generated summary

    PETER JOHN BUCKLE · 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

    Peter John Buckle was injured at work when a post propping open a trailer tailgate slipped, causing the tailgate to fall. He was airlifted to Addenbrooke's Hospital and died later that day from his injuries. Concerns included the failure to reassess the risks when the original work method became unavailable and an apparent lack of a health and safety culture at ground level.

    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 reassess work methods when the existing method is no longer viable

    Wider context from the report

    “(1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe. (2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for health and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level”. ”

    Source location

    PETER JOHN BUCKLE · 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

    Complete behavioural safety training to improve decision-making when tasks or circumstances deviate from normal procedures.

    Verbatim wording from the response

    “Wayland Farms Limited has put in place new programmes to deal with health and safety since the accident. We refer to Page 2 of the Health & Safety Executive’s Fatal Incident Report dated 28th April 2015 in this regard (copy attached marked Exhibit “1”). A training program based around behavioural safety with the aim of improving the safety culture within Wayland Farms Ltd has been completed, this was a blend of theory and practice in both an engaging and thought-provoking way to enable smarter decisions and actions in relation to tasks and situations occurring that fall outside of what is expected to be the normal procedure or activity.”

    Source location

    2015-0425-Response
    Page 1 · response
    Published 3 November 2015

    Open published response
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Data last updated 7 September 2026