Recurring concern

Failure to assess safety risks before using potentially dangerous equipment

First to latest report 28 Dec 2016 — 26 Jun 2023

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures to identify, assess and control safety risks associated with equipment before initial use, introduction, or use following a material change, including equipment capable of causing serious injury or death and the related pre-use or first-use risk assessment.

What is not included
  • Excludes generic risk-assessment deficiencies where no equipment-related hazard or equipment-use decision is identified.
  • Excludes routine equipment maintenance, inspection, servicing or operational-use failures where the deficiency is not the absence or inadequacy of a safety risk assessment before use.
  • Excludes clinical risk assessments concerning patients, diagnoses or treatments where equipment-related safety assessment is not the shared unsafe condition.
  • Excludes generic staff competence, training or documentation deficiencies unless they directly prevent risk assessment of potentially dangerous equipment.

Reports and published responses 2 reports

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

  1. Buckinghamshire

    AI-generated summary

    Anthony William Rockall · 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

    Anthony William Rockall died at John Radcliffe Hospital on 26 April 2022 from a head injury sustained when he fell from the tailgate of a truck during unloading at a reclamation yard. The pallet truck was longer than the tailgate, and concerns were raised about the unloading method, the weight on the tailgate, and the absence of subsequent reviews or changes to working practices, leaving risks of loads, equipment or individuals falling from the tailgate.

    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 equipment suitability for the task

    Wider context from the report

    “It was clear from the evidence that the pallet truck being utilised and the manner of unloading were incompatible with the truck being unloaded in that the pallet truck was longer than the tailgate of the truck and the method adopted required the pallet truck wheels to drop off the tailgate, grounding the load. There were also concerns expressed about the weight of the load, pallet truck and two individuals on the tailgate. Buckinghamshire Council evidence indicated a letter had been written to you on 27th September 2022 but your evidence was that this had never been received. The letter was described as informing you that you must review health and safety procedures at your premises, including the use of the pallet truck and the loading and unloading of client and casual workers’ vehicles. It was indicated you were also to assess the suitability of equipment for the task to be undertaken and to review who was permitted to use the equipment and when. Evidence at the Inquest was that there had been no review and no change of working practices since the incident involving Tony Rockall and that a pallet of bricks delivered on a truck such as was being used by Mr Rockall would be unloaded in exactly the same way now as then. It is clear that such practices could give rise to the toppling of a load, the pallet truck or an individual falling from a truck tailgate with the risk of fatal injuries arising. ”

    Source location

    Anthony William Rockall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Dorothea Jean Parr · 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

    Dorothea Parr fell from a newly delivered electric riser-recliner chair at home on 21 March 2016, sustained a fractured neck of femur, and died of pneumonia on 28 March 2016. The report raised concerns that the chair was delivered without notifying her family, carers, or district nurses, limiting opportunities for training and risk assessment. It also identified a lack of formal procedures for notifying district nurses about falls, changes in presentation, or new equipment.

    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 carry out appropriate risk assessments before use of new equipment

    Wider context from the report

    “At the inquest the evidence showed that the electric armchair had been ordered by the Occupational Therapist and delivered by Tremorvah Industries (Mobility) at short/no notice to Mrs Parr’s address on 21st March 2016. No notification was given to the son – who had requested to be present when it was delivered nor to the Occupational Therapist or Kerrier Home Care Ltd who provided the carers who would assist Mrs Parr in using the new chair. This meant there was limited or no opportunity for the family and carers or district nurses to be trained for or appropriate risk assessments to be carried out prior to the use of the new equipment or at the time of the first use. ”

    Source location

    Dorothea Jean Parr · 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

    Implement and embed the community slips, trips and falls policy, including falls risk assessments, care plans, incident reporting, and shared learning.

    Verbatim wording from the response

    “Standards for Better Health state that NICE clinical and public health guidance should be disseminated and implemented at all levels through a robust framework. The implementation of this policy will ensure that NICE guidance and NSF standards are being followed throughout the county for the management of falls.”

    Source location

    2016-0466-Response-by-Cornwall-Partnership-NHS-Trust.pdf
    Page 3 · response
    Published 28 December 2016

    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 embedded community falls policy and its risk-assessment requirements are considered sufficient, so no further action will be taken.

    Verbatim wording from the response

    “Standards for Better Health state that NICE clinical and public health guidance should be disseminated and implemented at all levels through a robust framework. The implementation of this policy will ensure that NICE guidance and NSF standards are being followed throughout the county for the management of falls.”

    Source location

    2016-0466-Response-by-Cornwall-Partnership-NHS-Trust.pdf
    Page 3 · response
    Published 28 December 2016

    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