8 May 2024 Sean Patrick O’CONNOR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to ensure required daytime checks on lone workers View source
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. 3
Action
Update the Contractor Handbook and Lone Working Policy to apply to contractors.
View source
Action
Trial a welfare-check process for lone workers applying for work authorisation, including prompts, competent-person checks, and system recording.
View source
Action
Review the six-month trial, assess its effectiveness, and decide whether further changes are needed.
View source
×
AI-generated summary
Sean Patrick O’CONNOR · 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
Sean O’Connor was electrocuted shortly after 10am on 24 November 2021 while changing a heat pump flow switch terminal during work in London. The report raised concern that lone workers might not receive the checks contemplated by the risk assessment, and that routine site discussions should remind workers whether checks are required during the day.
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 Canary Wharf Management Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure required daytime checks on lone workers
Wider context from the report “I heard evidence at inquest that, as he was regarded as a lone worker, Sean O’Connor could and, according to the risk assessment method statement (RAMS), should have asked a CWML colleague to come to check on him during the day. He did not ask for such a check and, although a CWML employee thought of doing so, that person was busy and so did not.
Whilst such a check is likely to have taken place too late in the day to have changed the outcome for Mr O’Connor, that might be different for another lone worker.
Several witnesses gave evidence that discussions take place with every worker coming on site as a matter of routine, covering such matters as where the worker is meant to be located, the exact nature of the job and so forth. The CWML director who gave evidence at inquest agreed with me that it would be a straight forward matter to include within that as a point always for brief discussion, whether any checks are required during the day . In this way, if the operative forgets to ask, the discussion can act as a reminder .
” 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 Update the Contractor Handbook and Lone Working Policy to apply to contractors.
Verbatim wording from the response “In addition to the above, CWML will be updating the Contractor Handbook and the Lone Working Policy to apply to contractors.” Source location Response from Canary Wharf Management
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 Trial a welfare-check process for lone workers applying for work authorisation, including prompts, competent-person checks, and system recording.
Verbatim wording from the response “Notwithstanding the above, and as part of a process of continuous improvement, CWML has decided to trial a new feature to apply to WA, beginning July 2024. The arrangements will include:” Source location Response from Canary Wharf Management
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 the six-month trial, assess its effectiveness, and decide whether further changes are needed.
Verbatim wording from the response “These arrangements will apply in addition to the independent contractors' procedures for lone working. The trial is intended to run for 6 months at the end of which CWML will review the results, consider their effectiveness and decide whether to implement some or all of the trial or make any further changes.” Source location Response from Canary Wharf Management
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 existing risk-based system and checks are considered adequate, and broader checks could divert resources from higher-risk work.
Verbatim wording from the response “CWML’s approach to facilitating access to its premises by independent contractors reflects what it understands to be recognised practice. CWML is not aware of any concerns raised by contractors (including Mitsubishi) before the incident involving Mr O'Connor. The existing CWML system prioritises checks based on risk (higher risk works requiring a PtW involve mandatory checks and are rarely performed by lone workers). CWML is mindful of the need to avoid potentially undermining the strengths of the system by diverting resource away from higher risk works.” Source location Response from Canary Wharf Management
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations