Recurring concern

Unreliable guidance and communication for safety risk assessments

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First reported 6 Jan 2014•Latest report 10 Apr 2025

Definition

What this concern includes

Includes failures to provide, explain, disseminate or maintain clear guidance and requirements for generic safety risk assessments where those failures impair the ability of responsible assessors or operational staff to assess hazards and apply the assessment correctly.

Not included

  • Excludes risk assessments belonging to a separately named safety system, pathway or hazard when that named concern provides the more specific supported boundary.
  • Excludes failures to carry out, update, record or act on a risk assessment when guidance and communication are not themselves deficient.
  • Excludes generic staff training or communication deficiencies that are not specifically tied to understanding or applying safety risk-assessment requirements.
  • Excludes failures concerning the competence of formal risk assessors where the primary issue is assessor qualification or training rather than availability and communication of assessment guidance.
Reports
8

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
6

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
Ambassador House1
BNF Publications1
British Association Of Dermatologists1
Coal Authority1
Cwm Taf Morgannwg University Local Health Board1
Department for Digital, Culture, Media and Sport1
Department of Health and Social Care1
DHL Supply Chain Limited1
Mineral Products Association1
Mining Remediation Authority1
Royal College of Psychiatrists1
Welsh Government1
West Mercia Police1
West Yorkshire Police1

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. Sunderland

    AI-generated summary

    Mr Joel Kenneth Ineson · 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

    Joel Kenneth Ineson died by drowning at Hetton Lyons County Park on 1 June 2023 after participating in an open water swimming event and suffering an unexpected cardiac event. The principal concerns were uncertainty about responsibility for safety measures, inadequate or absent safety briefings, lack of knowledge about participants and numbers in the water, and the absence of specific regulation, oversight and safety requirements for such events.

    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 health and safety guidance and compliance requirements for event risk assessments

    Wider context from the report

    “Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

    Source location

    Mr Joel Kenneth Ineson · 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

    Existing regulations and guidance provide a suitable basis for safe public open water swimming, so HSE will not publish specific guidance.

    Verbatim wording from the response

    “Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.”

    Source location

    Response from Health and Safety Executive
    Page 1 · response
    Published 17 April 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

    Enforcement responsibility lies with HSE or the relevant local authority, with local authorities predominantly enforcing work-related health and safety legislation in this area.

    Verbatim wording from the response

    “Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.”

    Source location

    Response from Health and Safety Executive
    Page 1 · response
    Published 17 April 2025

    Open published response

  2. South Wales Central

    AI-generated summary

    Christopher Kapessa · 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 Kapessa, aged 13, was intentionally pushed into the River Cynon at the Red Bridge on 1 July 2019, became submerged and could not be saved after resuscitation attempts. The report identified concerns about inadequate water-safety policies, unclear inspections and guidance, a lack of warning signage and rescue equipment, and remedial works that were not completed.

    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 inspectors with guidance for assessing safeguards against deep and fast-flowing water

    Wider context from the report

    “(4) Inspectors were not provided with any guidance as to how to assess whether members of the public accessing the site should be safeguarded from the risks of deep and fast flowing water, and if so how. No signage was in place to warn of the specific dangers of deep and fast flowing water. No consideration was given as to whether equipment to assist in the rescue of members of the public who may have got into difficulty, such as throw lines, should be provided. ”

    Source location

    Christopher Kapessa · 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

    Implement a Water Safety Procedure guiding risk assessment and decisions on signage, fencing, information and water-rescue equipment.

    Verbatim wording from the response

    “As stated in the letter of the 17 January 2024, the CA was at that time developing a water safety procedure. This sits alongside the CA’s procedure on safe working near water. The CA’s overarching health, safety and wellbeing policy, safe working near water procedure and new Water Safety Procedure are all attached for reference.”

    Source location

    Response from Browne Jacobson
    Page 3 · response
    Published 12 February 2024

    Open published response

  3. South Wales Central

    AI-generated summary

    David Edwin BLINMAN · 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 28 December 2018, David Edwin BLINMAN was walking home when he was struck by, or fell into the path of, a reversing articulated lorry and was crushed by its rear wheels. His death was declared at the scene. Concerns included inadequate risk assessments and mitigating measures for pedestrians in vehicle blind spots, the inability to conduct 360-degree checks while reversing without additional measures, and insufficient regard to Rule 202 of The Highway Code.

    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 require consultation with store operators and regular delivery drivers about hazards and concerns

    Wider context from the report

    “(1) DPRA’s do not mandate discussion with and documenting of, by the Risk Assessor, the views and experiences of the store owner/operator, nor of the drivers regularly delivering to the store, in relation to any particular hazards, or concerns. The Risk Assessor may not, therefore, be sufficiently informed of material which might assist him, or her in completing an adequate risk assessment. ”

    Source location

    David Edwin BLINMAN · 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

    Apply the revised Nisa DPRA process across delivery locations using risk-based prioritisation and weekly management oversight.

    Verbatim wording from the response

    “The DPRA process for the Nisa account has been specifically reviewed by the contract’s Account Management, under the direction of the Vice President of Operations and in conjunction with their Safety Team. The revised Safety Arrangement has already been introduced for that account. The Nisa contract has around 4,100 delivery points and a risk based approach will be adopted to reviewing order of the DРRAs for the account. We anticipate that this process will take in the region of six months to complete across all delivery locations and will be managed and controlled by a weekly management call containing representatives from all operating locations.”

    Source location

    2021-0054-Response-from-DHL-Redacted
    Page 2 · response
    Published 1 March 2021

    Open published response

  4. South Wales Central

    AI-generated summary

    Deidre Harvey · 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

    Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

    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 disseminate risk management policies clearly to frontline staff

    Wider context from the report

    “Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”

    Source location

    Deidre Harvey · 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

    Disseminate risk management policies through ward meetings and obtain individual staff sign-off.

    Verbatim wording from the response

    “Dissemination of risk management policies to frontline staff are now shared by team leaders through ward meetings and staff sign off individually to demonstrate sharing.”

    Source location

    2018-0266-Response-by-University-Health-Board
    Page 1 · response
    Published 20 July 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

    Responsibility for NHS matters in Wales is devolved and falls outside the scope of this England policy response.

    Verbatim wording from the response

    “Your report directs two matters of concern to the Secretary of State for Health which I will address in turn giving the policy position in England. You will appreciate that responsibility for the NHS in Wales is a devolved matter.”

    Source location

    2018-0266-Response-by-Department-of-Health-Social-Care
    Page 1 · response
    Published 20 July 2017

    Open published response

  5. Bedfordshire and Luton

    AI-generated summary

    ETHELINE DE-GALE · 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

    Etheline De-Gale fell while mobilising from bed at a care setting on the night of 7/8 March 2016. Hospital admission was declined, follow-up with a doctor did not occur as recommended, and an ambulance attended the following afternoon; she later underwent surgery, contracted bronchopneumonia and died from a pulmonary embolism on 16 March 2016. Concerns included an insufficiently clear care plan, inadequate guidance on risk assessments, limited staffing, and the apparent failure to follow paramedic recommendations.

    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 guidance for undertaking risk assessments

    Wider context from the report

    “(2) The Deputy Manager indicated that the carer should have undertaken a risk assessment, but could offer no guidance on how that was to be achieved. ”

    Source location

    ETHELINE DE-GALE · 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

    Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.

    Verbatim wording from the response

    “Based on the information from statements, staff interview, care plans, risk assessments and LR’s personnel file, we have concluded that in this case we have acted in accordance with our policies and procedures. The incident occurred, we believe, because of the negligence of a senior staff member (LR).”

    Source location

    2017-0058-Response-Ambassador-House-Home
    Page 3 · response
    Published 6 March 2017

    Open published response

  6. Shropshire, Telford and Wrekin

    AI-generated summary

    Tyrone Lock · 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

    Tyrone Lock left a hotel wearing only boxer shorts and socks on a cold, windy night and was found deceased two days later in a pond. The jury concluded that he should have been classified as a vulnerable person rather than an absconder, and that a second helicopter request should have been made; it identified police failings contributing to his death.

    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

    Inconsistent understanding of risk of harm among police duty sergeants

    Wider context from the report

    “(1) The jury concluded that Tyrone should have been assessed differently from the first male and should have been classified as a vulnerable person and not as a suspect that was absconding. (2) The jury believed that a second request for a helicopter should have been issued and that it would have been deployed and that in this case there would have been a chance to find Tyrone in a survivable state. (3) Collectively there was information available to the police from the OIS logs, what was said to them by the night manager and from their own observations that Tyrone’s departure could be described as “hallucinating, foaming/frothing at the mouth, spaced out on drugs, sweating, that he had ran out of the hotel wearing boxer shorts and socks only. It was very cold, 4 degrees, it was windy and he ran out into open ground with water courses with somebody out to get him and on the police log according to the night manager an ambulance probably would be a good idea.” It was on this evidence that the jury concluded that Tyrone should have been classified as a vulnerable person. (4) On that information witnesses from the National Police Air Service (NPAS) confirmed that they would have classified Tyrone as a vulnerable person and would have made every effort to deploy a helicopter to the scene. NPAS further indicated that because one request in the same incident had met with a refusal that did not mean a second request would also be refused. Each request would be dealt with on its own merits. Here a second call would have been treated as a top priority job. NPAS would not be concerned with why someone was running away from the police, their concern would be, having run away, that was he at risk of harm. (5) Contrary to the NPAS evidence the police officers concerned believed that, regardless of Tyrone’s status, a second call to NPAS would have met with the same result and there would be no point in making such a request. Further two duty sergeants involved on the Saturday and Monday mornings had different views as to what risk of harm meant. One thought it meant risk of suicide only, the other that it would extend to non-fatal or accidental harm. (6) As NPAS serves all police forces in England and Wales they are included in this report so that: a. They may liaise with West Mercia Police as to any lack of understanding as to what one may expect of the other. b. To review whether any other police force may also have a similar lack of understanding. ”

    Source location

    Tyrone Lock · 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

    Embed the National Decision Model across West Mercia for structured assessment and decision-making.

    Verbatim wording from the response

    “The use of the National Decision Making Model (NDM) is embedded across West Mercia. The NDM has six key elements. Each provides frontline officers and staff with an area for focus and consideration and can be applied to a range of circumstances.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 2 · response
    Published 26 February 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

    Introduce the THRIVE model across the force to support information gathering, risk assessment and public protection decisions.

    Verbatim wording from the response

    “We have complemented the NDM by introducing the THRIVE model, (Threat, Harm, Risk, Investigation, Vulnerability, Engagement) across the Force. NDM and THRIVE both provide a framework for officers and staff to seek out as much information that they can and make sound rational decisions to protect the public.”

    Source location

    2016-0355-Response-by-West-Mercia-Police
    Page 2 · response
    Published 26 February 2017

    Open published response

  7. Suffolk

    AI-generated summary

    ANTHONY STEPHEN CLEVELAND · 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 Stephen Cleveland collapsed after exercising unsupervised at a gym on 11 June 2013 and died some days later in intensive care following a cardiac arrest and hypoxic injury associated with severe coronary artery stenosis. Concerns included inadequate supervision and resuscitation, inadequate risk assessment, a lack of qualified first aiders, and the absence of formalised national guidance for risk assessment in fitness centres and gyms.

    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

    Absence of formalised national guidance on risk assessment in fitness centres and gyms

    Wider context from the report

    “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms. ”

    Source location

    ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. 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 to disseminate or explain risk assessments to staff operating the process

    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

    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
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Data last updated 7 September 2026