Concerns raised 6 Failure of managers and staff to access computer-based health and safety material View source Lack of clarity about activities constituting pressure testing View source Unavailability of clear operating instructions for the Enerpac pump View source Lack of a specific risk assessment or method statement for the work View source Inadequate compliance with PUWER and HSE pressure-testing guidance across the industry View source Lack of clear strategic and operational responsibility for health and safety issues View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Develop a communications strategy explaining the safety management system, its rules and staff responsibilities.
View source
Action
Appoint a Safety Officer/Assistant Manager with operational workshop safety experience.
View source
Action
Remind all staff about the health and safety policy and where to access it.
View source
Action
Expand the Paint Shop Supervisor role to Workshops Supervisor to support implementation of site-wide safety rules and controls.
View source
Action
Review risk assessments, COSHH assessments and safe systems of work following the accident.
View source
Action
Work with the HSE and health and safety consultants to establish comprehensive risk assessments and safe systems of work.
View source
Action
Review the site safety induction with specialist advice and provide refresher training on safety roles and hierarchy.
View source
Action
Develop task-specific safe systems of work and deliver toolbox talks to relevant employees, maintaining records and discussing them through the safety committee.
View source
Action
Roll out refresher training and awareness raising so employees know where to find health and safety documents.
View source See 6 more actions
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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. The report was sent to Agd Equipment Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of managers and staff to access computer-based health and safety material
Wider context from the report “(4) AGD managers and staff had not accessed computer-based material relating to health and safety issues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Agd Equipment Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about activities constituting pressure testing
Wider context from the report “(1) There was a lack of clarity as to what type of activity amounted to pressure testing.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Agd Equipment Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of clear operating instructions for the Enerpac pump
Wider context from the report “(3) No instruction manual had been provided to AGD to give clear instruction on how the Enerpac pump should be used .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Agd Equipment Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific risk assessment or method statement for the work
Wider context from the report “(2) There was no specific risk assessment or method statement for the type of work being carried out by Mr Seward.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Agd Equipment Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate compliance with PUWER and HSE pressure-testing guidance across the industry
Wider context from the report “(2) The degree of compliance with the Provision and Use of Work Equipment Regulations 1998 (PUWER) and guidance issued by the HSE such as GS4 was called into question , not only at AGD but more widely within the industry. Witnesses gave evidence that the poor practices followed at AGD were replicated elsewhere .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Agd Equipment Limited; that does not assign responsibility.
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.
” Open source report
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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
Open published response
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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
Open published response
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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
Open published response
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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
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 risk assessments, COSHH assessments and safe systems of work following the accident.
Verbatim wording from the response “Following the accident on 27th May 2015 the company reviewed all risk assessments, COSHH assessments and safe systems of work. AGD’s health and safety consultants were involved in this process and the Supervisory Team must access and use these documents when planning new tasks, or allocating work to personnel.” Source location SEWARD-Response
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 Work with the HSE and health and safety consultants to establish comprehensive risk assessments and safe systems of work.
Verbatim wording from the response “4. AGD are working closely with the HSE to ensure that risk assessments and safe systems of work are in place. AGD are also working with the close assistance of the company’s health and safety consultants throughout this process to identify all risks, work duties and equipment, to ensure nothing is overlooked.” Source location SEWARD-Response
Open published response
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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
Open published response
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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 task-specific safe systems of work and deliver toolbox talks to relevant employees, maintaining records and discussing them through the safety committee.
Verbatim wording from the response “Having drawn up individual safe systems of work, toolbox talks were delivered to all employees likely to be involved in the relevant tasks to ensure that they understood the task and the controls in place to work safely. A full record is kept of these toolbox talks, and they continue to be discussed by the Health and Safety Committee at monthly meetings to ensure a rolling programme of continuous improvement.” Source location SEWARD-Response
Open published response
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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 Roll out refresher training and awareness raising so employees know where to find health and safety documents.
Verbatim wording from the response “The company health and safety documents including the policy, risk assessments and safe systems of work along with relevant HSE Guidance are held electronically on servers and computers. The company has also given the mobile engineers electronic tablets containing these documents for off-site reference. A hard copy of all electronic documents is also held in folders located in the Service Department office. This was already the case at the time of the Inquest and was within knowledge of those employees who gave evidence because they were part of the team directly involved in putting the documentation together. It is not known why this information was not given to the Coroner at the Inquest. Refresher training and awareness raising has been rolled out across all employees to remind them where all health and safety documents can be found.” Source location SEWARD-Response
Open published response
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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 Health and safety documents were available electronically and in hard copy, contrary to any premise that the company lacked accessible documentation.
Verbatim wording from the response “The company health and safety documents including the policy, risk assessments and safe systems of work along with relevant HSE Guidance are held electronically on servers and computers. The company has also given the mobile engineers electronic tablets containing these documents for off-site reference. A hard copy of all electronic documents is also held in folders located in the Service Department office. This was already the case at the time of the Inquest and was within knowledge of those employees who gave evidence because they were part of the team directly involved in putting the documentation together. It is not known why this information was not given to the Coroner at the Inquest. Refresher training and awareness raising has been rolled out across all employees to remind them where all health and safety documents can be found.” Source location SEWARD-Response
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations