30 Apr 2026 Kevin Lapwood · Prevention of Future Deaths report Berkshire
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Concerns raised 5 Lack of requirement for HSE medical doctors to confirm advice about immersion pulmonary oedema risks View source Insufficient awareness of immersion pulmonary oedema risks for divers with high blood pressure View source Insufficient guidance on the duties of shore support or surface cover View source Insufficient training and awareness of medical requirements for volunteer divers View source Ambiguity in legislation and guidance about applicability to volunteer divers View source See 2 more concerns
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AI-generated summary
Kevin Lapwood · 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
Kevin Lapwood, aged 63, was acting as a volunteer safety diver at Wraysbury Dive Centre on 12 February 2022 after failing an HSE medical in October 2021. He got into difficulty in very cold water and died at Wexham Park Hospital the next day; the recorded cause of death was immersion pulmonary oedema, hypertension and coronary artery disease. Concerns included medical requirements and awareness for volunteer divers, awareness of immersion pulmonary oedema risks, the guidance on shore support, and potential ambiguity in HSE legislation and guidance concerning volunteers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of requirement for HSE medical doctors to confirm advice about immersion pulmonary oedema risks
Wider context from the report “3. I am concerned that there is currently no requirement for doctors conducting HSE medicals to confirm that they have advised patients who fail the HSE medical , for reasons similar to those in Kevin’s case, of the risks of IPO .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient awareness of immersion pulmonary oedema risks for divers with high blood pressure
Wider context from the report “2. I am concerned about the level of training and awareness around the risks of immersion pulmonary oedema(“IPO”) for divers with high blood pressure . Whilst the more common risks of hypertension will be better understood (such as heart attack and stroke), awareness of IPO appears to be less well understood .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance on the duties of shore support or surface cover
Wider context from the report “3. I am concerned about whether there is sufficient guidance regarding what the role of shore support /surface cover entails . Specifically, should that include having eyes on the water?
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and awareness of medical requirements for volunteer divers
Wider context from the report “1. I am concerned about the level of training and awareness nationally – specifically of the medical requirements for volunteers involved in projects like Kevin was .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in legislation and guidance about applicability to volunteer divers
Wider context from the report “1. Clarity of the approved code of practice (‘ACOP’) entitled “Recreational diving projects – Diving at Work Regulations 1997”, published in 2014, in the following respects:
a. The title of the document – does this document adequately reflect that it also covers volunteers? Is there a risk that, on reading the initial heading of the document, it may be felt that it is not relevant to volunteers working in the capacity that Kevin did?
b. Would the reference to “associated guidance” on the title page be better with the use of a hyperlink to guidance such as the volunteer diver guidance note?
c. The definition of “diver” in the ACOP is “a person at work who dives”. The definition of “at work” is (in summary) an employee or a self-employed person. Although the guidance does go on to deal separately with those in a diving role as part of a project, there is some potential ambiguity here . For instance, it may be possible to look at the guidance on Regulation 12 which states that no “diver” shall dive in a diving project unless he has an HSE medical. If “diver” is defined as being somebody at work, then there is a risk that the regulations could be interpreted in the way it appears they were here – ie only applying to somebody who is paid.
A careful reading of the guidance should make the position clearer, but I believe there is a remaining risk of misinterpretation without very careful analysis of this document .
2. All the titles of the relevant legislation and guidance refer to diving “at work”. It is easily foreseeable that someone looking at this may assume that it is not relevant for volunteers used as part of a diving project . I appreciate that naming legislation is not within the gift of the HSE, but it may be something that could be communicated in relation to future legislation, and taken into account in HSE guidance – particularly the titles of any future guidance.
” 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 Produce and publish volunteer diver guidance clarifying medical fitness requirements for volunteers essential to diving projects.
Verbatim wording from the response “To address this HSE has taken several steps:-” Source location Response from Health and Safety Executive
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind approved medical examiners of the importance of explaining diving implications of medical conditions, particularly when divers are found unfit for work.
Verbatim wording from the response “Through our ongoing engagement with the AMEDs we will remind them of the importance of explaining the implications of medical conditions for diving, particularly where a person is found unfit to dive at work.” Source location Response from Health and Safety Executive
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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 PADI to promote guidance helping recreational diving members comply with the Diving at Work Regulations.
Verbatim wording from the response “2. HSE have worked with the Professional Association of Diving Instructors (PADI) as the largest provider of recreational diver training in GB, where the instructor or other divers are likely to be at work. Since 2004 PADI have published on their own website guidance on how its members should ensure compliance with DWR. This guidance contains near identical wording to the HSE volunteer diver guidance above. http://apsto.org.uk/wp-content/uploads/2023/01/2022-Diving-at-Work-Regulations-advice-from-PADI-2022.pdf” Source location Response from Health and Safety Executive
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use industry liaison and annual recreational diving trade-show attendance to educate the diving community about medical fitness requirements.
Verbatim wording from the response “3. Through industry liaison with the British Diving Safety Group and annual attendance at recreational diving trade shows, HSE diving specialist inspectors have sought to educate the recreational diving community on the importance of medical fitness to dive and in particular the requirement for any person whose involvement in a diving project is core to the minimum legally required diving team, to be properly assessed as medically fit by holding a valid certificate of medical fitness to dive.” Source location Response from Health and Safety Executive
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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 and update volunteer diving guidance to provide clear, unambiguous information, taking account of the coroner’s concerns.
Verbatim wording from the response “HSE is currently in the process of reviewing and updating its guidance including the volunteer diving guidance document. HSE is committed to ensuring that it provides clear, unambiguous guidance and will be cognisant of the matters you have raised when the ACoP is next reviewed.” Source location Response from Health and Safety Executive
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The recreational diving ACoP applies only to diving projects under DWR, not purely leisure dives by members of the public.
Verbatim wording from the response “With regards to the “Recreational diving projects – Diving at Work Regulations 1997” approved code of practice (ACoP), the title of the document reflects that it is applicable only to diving projects which come under DWR, and not to dives conducted purely for leisure purposes by members of public.” Source location Response from Health and Safety Executive
Open published response
Concerns raised 4 Inability of batch sample non-destructive testing to guard against rare isolated hidden defects in individual parts View source Proximity of inspectors beneath raised and pressurised air suspension systems during visual pre-delivery inspections View source Lack of sector-wide awareness of inspection-phase proximity risk View source Failure of national guidance to address unexpected component failure during undisturbed visual inspection View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Richard Gary Hopkins · 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
Richard Gary Hopkins sustained fatal injuries when a defective trailing arm suddenly failed while he was beneath the rear axle of a newly assembled vehicle during a visual pre-delivery inspection. The principal concerns were an unrecognised risk from proximity beneath raised and pressurised air suspension during undisturbed inspection, a lack of guidance addressing that risk, the limitations of batch sample testing, and limited awareness of the risk across the sector.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Inability of batch sample non-destructive testing to guard against rare isolated hidden defects in individual parts
Wider context from the report “c) Limitations of batch sample testing
Batch sample non-destructive testing , although widely accepted for components not designated as safety critical, cannot fully guard against a rare, isolated hidden defect in an individual part . Inspectors may therefore be unknowingly positioned beneath a component capable of unexpected failure under pressure.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Proximity of inspectors beneath raised and pressurised air suspension systems during visual pre-delivery inspections
Wider context from the report “a) Previously unrecognised proximity risk
The investigation revealed a previously unrecognised proximity risk to inspectors working beneath raised and pressurised air suspension systems during visual pre delivery inspections. Although the defect in this case was exceptionally rare, a sudden and undetectable failure in these circumstances presents a clear risk of fatal injury .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of sector-wide awareness of inspection-phase proximity risk
Wider context from the report “d) Lack of awareness of this inspection phase risk across the sector
The evidence demonstrated that the inspection phase proximity risk identified in this case was not appreciated by the employer or more widely within the sector . The measures introduced after the incident show that the risk can be effectively eliminated once recognised, but its existence had not been understood before this incident .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure of national guidance to address unexpected component failure during undisturbed visual inspection
Wider context from the report “b) Absence of guidance addressing failure during undisturbed inspection
Existing national guidance recognises the possibility of component failure when work is being carried out on a pressurised suspension system. It does not address the distinct risk demonstrated by this incident: that a component may also fail unexpectedly during an undisturbed visual inspection when the operative is not working on the system.
” 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 Raise awareness among relevant stakeholder groups of the incident and findings from the inquest and HSE investigation.
Verbatim wording from the response “We have worked with stakeholder groups including the MVRF to raise awareness of the circumstances of this incident and the findings of both the Inquest and our own investigation. We will continue to explore opportunities to raise awareness of this risk in relevant industry sectors going forward.” Source location Response from HSE
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue exploring opportunities to raise awareness of the inspection-phase risk across relevant industry sectors.
Verbatim wording from the response “We have worked with stakeholder groups including the MVRF to raise awareness of the circumstances of this incident and the findings of both the Inquest and our own investigation. We will continue to explore opportunities to raise awareness of this risk in relevant industry sectors going forward.” Source location Response from HSE
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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 Participate in reviewing HSE guidance with specific consideration of the incident and pre-delivery inspection risk.
Verbatim wording from the response “Following a recent meeting of the Motor Vehicle Repair Forum (MVRF) on the 8th of May, MVRF members agreed to review the HSE guidance documents INDG 434, HSG 261 and PM85 with specific consideration for the incident involving Mr Hopkins.” Source location Response from HSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation DVSA, as the enforcing authority, investigated component safety and batch testing and raised no further concerns about the design or manufacturing process.
Verbatim wording from the response “As the enforcing authority for the safety of components on road-going vehicles, the Driver and Vehicle Standards Agency (DVSA) undertook an investigation on the component which failed and tested samples from the same production batch. The findings of this investigation were shared with us during our own investigation, and I” Source location Response from HSE
Open published response
Concerns raised 2 Unsafe and difficult emergency access to the location View source Failure to secure the accessible location against ligature use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brody O'Brien · 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 7 October 2025, Brody O'Brien, aged 12, died after being found hanging at a redacted location in Rochdale. Concerns included that the area remained unsecured and could be accessed to secure a ligature, and that emergency services faced difficult and treacherous access while carrying equipment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Unsafe and difficult emergency access to the location
Wider context from the report “(2) Emergency services found access to the ████████ particularly with their equipment, difficult and treacherous . They had to scale a wall and once inside, the ground was very uneven and dangerous posing a significant risk .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to secure the accessible location against ligature use
Wider context from the report “(1) Brody was able to access the ████████ as it remains unsecured and use the ████████ to secure a ligature .
” 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 Improve site security and fencing around the development site bordering the mill.
Verbatim wording from the response “HSE does not have any enforcement responsibility for the disused mill as there is no ongoing work activity. However, the mill building is bordered on two sides by a site under the control of Spenside Developments Ltd which is enforced by HSE. We inspected the site in November 2025 and took enforcement action with regard to improvements to site security. A further visit was made on 17th March 2026 to re-assess site security and the necessary improvements to the site fencing have been made.” Source location 2026-0084 - Response from HSE
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with Rossendale Borough Council and share advice to further secure access to the mill building.
Verbatim wording from the response “Liaison with legal and planning representatives from Rossendale Borough Council took place to share concerns and ensure that both organisations are working together in an effective and cooperative manner. Representatives from Rossendale Borough Council were in attendance on 17th March and advice has been shared with regard to further securing access to the mill building.” Source location 2026-0084 - Response from HSE
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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 for the disused mill falls outside the remit because there is no ongoing work activity.
Verbatim wording from the response “HSE does not have any enforcement responsibility for the disused mill as there is no ongoing work activity. However, the mill building is bordered on two sides by a site under the control of Spenside Developments Ltd which is enforced by HSE. We inspected the site in November 2025 and took enforcement action with regard to improvements to site security. A further visit was made on 17th March 2026 to re-assess site security and the necessary improvements to the site fencing have been made.” Source location 2026-0084 - Response from HSE
Open published response
5 Dec 2025 Leonardo Cardoso Machado · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Children working alone at night delivering to private homes View source Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles View source Lack of oversight of the rental of food delivery licences to children under 18 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leonardo Cardoso Machado · 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
Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle while travelling at speed and colliding with metal railings. The report raised concerns about limited oversight of rented food delivery licences being provided to children under 18, and the resulting risks of lone night work and road traffic collisions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Children working alone at night delivering to private homes
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position ;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of the rental of food delivery licences to children under 18
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit . This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age , which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” 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 Update and publish joint guidance on driving and riding safely for work.
Verbatim wording from the response “The Department for Transport (DfT) commented that the safety of anyone driving or riding on our roads is a priority, and that includes those who drive for work. The government expects that employers or engagers of anyone driving or riding for work to ensure that they are as safe as possible on our roads. DfT worked closely with the HSE to update the joint DfT/HSE guidance on work related road safety. The revised guidance, published in September 2021 and called Driving and riding safely for work, clearly sets out what commercial organisations and their workers, whether employees” Source location Response from HSE & Gov Dept
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide guidance addressing risks, training, supervision, monitoring and support for lone workers.
Verbatim wording from the response “It is well known and established that lone working can present a risk to workers, and this should form part of an employer’s risk assessment. This includes the requirement to assess risks and should consider ways in which the work can be organised to minimise the potential for harm. Relevant training, supervision, monitoring and support should be provided for lone workers. HSE specifically considers lone workers in providing guidance and this covers both the employers of lone workers and the lone workers themselves; Lone working - HSE.” Source location Response from HSE & Gov Dept
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Practical limits constrain measures addressing lone working in delivery driving because the work inherently involves solo, deadline-driven and often nighttime activity with road risks.
Verbatim wording from the response “However, HSE acknowledges that there are practical limits to what can be done in the driver delivery sector because work like this inevitably involves working alone, to deadlines, often at night and with the attendant road risks.” Source location Response from HSE & Gov Dept
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Child-employment restrictions do not apply to a 17-year-old classified as a young worker.
Verbatim wording from the response “HSE has some high-level guidance on the employment of young people under the age of 18: Young people at work: Overview - HSE. The Department for Education state that the restrictions on child employment in the Children and Young Person’s Act 1933 apply to children who are of compulsory school age. Therefore, these restrictions would not apply in the case of Leonardo Cardoso Machado who, as a 17-year-old, would be classed as a ‘young worker’.” Source location Response from HSE & Gov Dept
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Department for Business and Trade is the more appropriate government body for concerns about renting food-delivery licences to under-18s.
Verbatim wording from the response “The Department for Business and Trade (DBT) are the more appropriate governmental body, and they have addressed the practice of “renting” food delivery licences to under 18’s and the concerns that this raises.” Source location Response from HSE & Gov Dept
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sharing permits is a contractual issue over which HSE has no control.
Verbatim wording from the response “The sharing of permits between licence owners and “substitutes” is a contractual issue and not an area HSE has any control over.” Source location Response from HSE & Gov Dept
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Road traffic accidents are generally for the police to investigate and enforce rather than HSE.
Verbatim wording from the response “In respect of the road traffic accident itself, HSE views that road traffic accidents are generally a matter for the Police to investigate and enforce, rather than HSE, using the most applicable legislation. This is set out in Health and Safety at Work etc Act 1974 - Section 3.” Source location Response from HSE & Gov Dept
Open published response
Concerns raised 3 Absence of a Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements View source Failure to give orders securing evidence for domestic explosion investigations View source Lack of understanding of evidence requiring preservation during domestic explosion investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brian Lyn Davies · 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
Brian Lyn Davies was pronounced dead at his home on 13 March 2023 after sustaining chest and neck injuries in an explosion. The cause of the explosion could not be determined because material evidence was not preserved during the search and rescue and clean-up operations, and concerns were raised about the lack of guidance or a protocol between the Police and the HSE on preserving evidence from domestic explosions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Absence of a Police-HSE memorandum of understanding or protocol for domestic explosion evidence requirements
Wider context from the report “During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to give orders securing evidence for domestic explosion investigations
Wider context from the report “During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence ;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of evidence requiring preservation during domestic explosion investigations
Wider context from the report “During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion may not be secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion ;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
” 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 Develop a proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.
Verbatim wording from the response “• Provide an update to the NLC on other HSE on-going work to develop a proposed ‘Suspected Gas Explosion checklist’, to sit alongside the current ‘Carbon Monoxide checklist’ within Appendix 1 of the WRDP Practical Guide – ‘Additional duties of first officer – Domestic Gas Incidents’. This would be for the NLC to agree and update the guide.” Source location Response from HSE
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 Prepare national training material on work-related aspects of investigations, including advice for first responders.
Verbatim wording from the response “• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;” Source location Response from HSE
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 National Liaison Committee owns the protocol and must agree proposed updates, including a suspected gas explosion checklist.
Verbatim wording from the response “The purpose of the protocol and supporting (practical) guide is to ensure effective joint investigation of work-related deaths in England and Wales. The WRDP National Liaison Committee (NLC), ‘owns’ the protocol and HSE sits on the committee alongside the other signatories.” Source location Response from HSE
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 Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.
Verbatim wording from the response “In relation to the specific ‘Matters of Concern’ raised in your letter, it is HSE’s opinion that the Work Related Death Protocol (WRDP) addresses your points. I have responded to each of those points individually with excerpts from the protocol below.” Source location Response from HSE
Open published response
10 Sep 2025 Stuart GILCHRIST · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1 Failure to make restaurants and food establishments aware of choking-rescue equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stuart GILCHRIST · 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
Stuart GILCHRIST, aged 77, died after choking on food at a restaurant during an outing with care home staff and other service users. Despite prompt first aid, emergency treatment and CPR, he was declared deceased. The principal concern was that restaurants and food establishments may not be aware of, or have access to, LifeVac-type suction devices that may assist during choking incidents.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to make restaurants and food establishments aware of choking-rescue equipment
Wider context from the report “1. During the evidence it was heard that there is a device that may assist in incidents of choking, it was referred to as a LifeVac (this may be a trade name). The care staff member, had recognised that Mr GILCHRIST was choking and while administering assistance to him had the foresight to ask if the restaurant had a “LifeVac” style device.
2. It was acknowledged during the inquest that restaurants have first aid items and some may have equipment such as a defibrillator however they may not be aware that this useful item exists, nor that it is relatively inexpensive.
3. At the time the evidence was heard, I was unaware of who would be responsible for advising restaurants and food establishments of the availability of such an item, or to raise with those outlets its usefulness should a customer begin to choke ; so therefore this RPFD is sent to three organisations who may have varying levels of responsibility - without restaurants and food establishments being made aware of such an item, they may not think to purchase one and retain it within their first aid armoury .
4. I also appreciate that LifeVac is probably a trade name and I only use it to describe the type of item that would be deemed useful.
” Open source report
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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 Regulating, approving or promoting anti-choking devices is outside the respondent’s regulatory remit.
Verbatim wording from the response “There is no requirement within these regulations for employers to provide specific pieces of equipment such as anti-choking devices. HSE is not the responsible body for regulation of such medical equipment and it is not within our regulatory remit to approve or promote their use.” Source location Response from Health and Safety Executive
Open published response
21 Jul 2025 Jean DYE · Prevention of Future Deaths report Greater Lincolnshire
View report summary
Concerns raised 4 Unavailability of an in-room EPO circuit reset control View source Lack of guidance on remote siting of Emergency Power Off controls View source Accidental activation of Emergency Power Off circuits overriding emergency power backup systems View source Lack of in-room indication of Emergency Power Off circuit activation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jean DYE · 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
Jean Dye died at Scunthorpe General Hospital after an artery dissection during a cardiac procedure, followed by an unexpected electrical power failure that delayed emergency stenting for approximately 10 minutes. The principal concerns were that activation of the Emergency Power Off circuit overrode backup power, there was no indicator or local reset control in the treatment room, and guidance on the location of such controls and related training may require review.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an in-room EPO circuit reset control
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room , the downtime would likely have been significantly reduced . Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on remote siting of Emergency Power Off controls
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room . I invite review of that guidance and of the need for any consequential training.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Accidental activation of Emergency Power Off circuits overriding emergency power backup systems
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of in-room indication of Emergency Power Off circuit activation
Wider context from the report “The circumstances of Mrs Dye's death are set out above. Her death arose as a consequence of the combination of an iatrogenic injury sustained during a clinical procedure and an untimely loss of power to the Catheter Lab where she was being treated for a period of approximately ten minutes at exactly the time at which her treating consultant required the benefits of real time x ray to facilitate a necessary emergency stenting procedure. The delay whilst power was restored was a critical factor in this death.
The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence. All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
I received evidence of a small number of accidental activations of EPO circuits nationally over a 12 month period. It is plainly something which can, and does, occur.
Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who inturn had to attend a separate plant room, the downtime would likely have been significantly reduced. Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.
” Open source report
Concerns raised 2 Limited awareness of platform-lift risks and hold-to-run device retrofit feasibility View source Lack of hold-to-run controls on platform lifts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Mary LANGWORTHY · 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
Jacqueline Mary Langworthy, an experienced care assistant, died after becoming trapped and pinned by a stand aid in a descending platform lift; resuscitation was unsuccessful. The principal concerns were that many platform lifts lack hold-to-run controls, these controls may be relatively inexpensive to retrofit, and awareness of the risks and retrofit feasibility is limited.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Limited awareness of platform-lift risks and hold-to-run device retrofit feasibility
Wider context from the report “(1) Many platform lifts still in use in care settings and other premises do not have hold-to-run controls.
(2) Evidence was received indicating that such controls can be retrofitted at relatively low cost.
(3) There is limited awareness of both the risks posed by the absence of hold-to-run devices and the feasibility of fitting such devices to existing platform lifts.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of hold-to-run controls on platform lifts
Wider context from the report “(1) Many platform lifts still in use in care settings and other premises do not have hold-to-run controls.
(2) Evidence was received indicating that such controls can be retrofitted at relatively low cost.
(3) There is limited awareness of both the risks posed by the absence of hold-to-run devices and the feasibility of fitting such devices to existing platform lifts.
” 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 Request that the platform-lift safety concern be raised with local authority enforcement officers through the national practitioner forum and a technical bulletin.
Verbatim wording from the response “To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm) and in a technical LA bulletin. I have also asked that the circumstances be shared with CQC, from a patient safety perspective, in a healthcare bulletin, to the wider healthcare industry and widely within the industry.” Source location Response from Health and Safety Executive
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 Request dissemination of the platform-lift safety concern to CQC, the healthcare industry and the wider industry through relevant bulletins and communications.
Verbatim wording from the response “To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm) and in a technical LA bulletin. I have also asked that the circumstances be shared with CQC, from a patient safety perspective, in a healthcare bulletin, to the wider healthcare industry and widely within the industry.” Source location Response from Health and Safety Executive
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 Dutyholders must assess lift risks and determine reasonably practicable controls; HSE does not require them to retrofit hold-to-run controls.
Verbatim wording from the response “There is currently no legal requirement to retrofit hold-to-run controls. As employers those managing/running care homes have responsibilities under health and safety law to ensure, so far as is reasonably practicable, the health and safety of their staff and others who might be affected, such as residents and visitors. They are required to carry out risk assessments. As a minimum the employer is expected to:” Source location Response from Health and Safety Executive
Open published response
10 Apr 2025 Mr Joel Kenneth Ineson · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 8 Lack of emergency plans for organised open water swimming events View source Failure to maintain an accurate record of who is in the water and how many people are in the water View source Unclear responsibility for safety measures at organised open water swimming events View source Lack of specific health and safety guidance and compliance requirements for event risk assessments View source Lack of regulatory licensing and oversight for organised open water swimming events View source Lack of training requirements for open water swimming event organisers View source Lack of knowledge of participant competency and capability View source Failure to provide specific pre-session safety briefings View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency plans for organised open water swimming events
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.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate record of who is in the water and how many people are in the water
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.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for safety measures at organised open water swimming events
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.
” 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 Health and Safety Executive; that does not assign responsibility.
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.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory licensing and oversight for organised open water swimming events
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.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of training requirements for open water swimming event organisers
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.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of participant competency and capability
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.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specific pre-session safety briefings
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.
” 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 Continue supporting and liaising with local-authority regulatory partners on enforcement of work-related health and safety legislation.
Verbatim wording from the response “HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area.” Source location Response from Health and Safety Executive
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
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 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
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 An AALA licence is not relevant because the licensing scheme concerns specified tuition for children, not adult swimming events.
Verbatim wording from the response “The Adventure Activities Licensing Regulations 2004 have a very specific purpose and were never intended to apply to all adventure activities or adult adventure activities. The Adventure Activities Licensing Authority (AALA) licence is aimed at those who provide tuition in specified adventure activities to children, and therefore it was not relevant to a swimming event for adults.” Source location Response from Health and Safety Executive
Open published response
25 Mar 2025 Peter David Konitzer · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 3 Failure to emphasise written risk assessments and method statements for construction work where no legal writing requirement applies View source Failure to guide volunteer-reliant organisations on obtaining professional advice and assistance when appropriate View source Inadequate standalone guidance on the obligations of charitable trusts and voluntary organisations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter David Konitzer · 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 David Konitzer, a volunteer working on the rehabilitation of a canal lock, died when a recently excavated retaining wall collapsed onto him while he was removing props. The inquest concluded that he died from compression of the chest and that he was unlawfully killed. The principal concerns related to inadequate management of construction work involving volunteers, including failures concerning temporary works designs, risk assessments, method statements and other required safety documentation, and to the adequacy of HSE guidance for voluntary organisations.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to emphasise written risk assessments and method statements for construction work where no legal writing requirement applies
Wider context from the report “1. The HSE website has a section on Volunteering which provides links to more detailed sections elsewhere on the website. No where is it emphasised that as a matter of good practice before undertaking any construction work risk assessments and method statements should be in writing even when there is no legal requirement to do so. Many charitable trusts have a large number of volunteers working for them but with under 5 actual employees technically escape the legal requirements for such documents to be in writing.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to guide volunteer-reliant organisations on obtaining professional advice and assistance when appropriate
Wider context from the report “3. Will thought be given to revising the Volunteering section of the website to provide a more comprehensive and standalone guide to the obligations of charitable trusts and voluntary organisations? Might such revision profitably include a section reminding organisations that rely on volunteers that enthusiasm should be tempered by being mindful of the need to obtain proper professional advice and assistance in appropriate circumstances ?
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Inadequate standalone guidance on the obligations of charitable trusts and voluntary organisations
Wider context from the report “3. Will thought be given to revising the Volunteering section of the website to provide a more comprehensive and standalone guide to the obligations of charitable trusts and voluntary organisations ? Might such revision profitably include a section reminding organisations that rely on volunteers that enthusiasm should be tempered by being mindful of the need to obtain proper professional advice and assistance in appropriate circumstances?
” 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 Consider the coroner’s recommendations when next reviewing the volunteering guidance pages.
Verbatim wording from the response “Q3, Will thought be given to revising the volunteering section of the website to prove a more comprehensive and standalone guide to the obligations of charitable trusts and voluntary organisations? Might such revision probably include a section reminding organisations that rely on volunteers that enthusiasm should be tempered by being mindful of the need to obtain proper professional advice and assistance in appropriate circumstances?” Source location Response from HSE
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 HSE cannot specifically advise voluntary organisations to maintain written risk assessments where fewer than five employees because this would exceed legal requirements.
Verbatim wording from the response “The requirement to record the assessment if there are five or more employees comes after the requirement to assess the risks. Therefore, the requirement to adequately control risks arising from the work applies regardless of the number employed. The assessment of the risk is the means by which the necessary controls are identified rather than a control in and of itself.” HSE is not able to place guidance on its webpages that goes above and beyond the law, which would be the case if we specifically asked or advised voluntary organisations to have a written risk assessment, even if they did not have five or more employees.” Source location Response from HSE
Open published response
24 Jan 2025 Neville Daniel Elisha MCKENZIE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of knowledge of anti-choking devices in care settings View source Failure to make anti-choking devices available in care homes serving residents at high risk of choking View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neville Daniel Elisha MCKENZIE · 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
Neville Daniel Elisha MCKENZIE died in hospital on 25 August 2024 after choking at his care home on 13 August 2024, which led to cardiac arrest and an unsurvivable brain injury. The report raised concerns about limited awareness and availability of anti-choking devices in care settings, including homes with residents at high risk of choking.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of anti-choking devices in care settings
Wider context from the report “1. The inquest heard evidence from ████████, Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. ████████ explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. ████████ explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available.
2. ████████, who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home .
3. I heard evidence that the devices are relatively inexpensive and do not require extensive training.
4. ████████ evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths.
5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to make anti-choking devices available in care homes serving residents at high risk of choking
Wider context from the report “1. The inquest heard evidence from ████████, Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. ████████ explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. ████████ explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available.
2. ████████, who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.
3. I heard evidence that the devices are relatively inexpensive and do not require extensive training.
4. ████████ evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths .
5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced .
” 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 Regulation of anti-choking medical devices rests with MHRA.
Verbatim wording from the response “• anti-choking devices are medical devices for which the Medicines & Healthcare products Regulatory Agency (MHRA) are the UK regulator” Source location Response from HSE
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 Regulation of care providers using anti-choking devices rests with CQC.
Verbatim wording from the response “• 1st Care Limited are a service provider registered with the Care Quality Commission (CQC), and therefore regulation of this and similar care providers falls under their enforcement responsibility” Source location Response from HSE
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 HSE considers anti-choking-device concerns outside its regulatory and policy-lead remit.
Verbatim wording from the response “Following consideration of these factors, I respectfully advise that HSE is not the appropriate regulator or policy lead to address this concern relating to anti-choking devices because:” Source location Response from HSE
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 Health and social care policy and delivery in England rests with DHSC.
Verbatim wording from the response “• the Department of Health and Social Care (DHSC) are the government department that leads on health and social care policy and delivery in England.” Source location Response from HSE
Open published response
26 Nov 2024 Jon-Paul PRIGENT · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3 Failure of current agricultural tractor and trailer safety arrangements to keep pace with changing road use View source Lack of periodic independent vehicle testing for tractors and trailers used on roads for agricultural purposes View source Failure to require safety features preventing decoupling of tractors and trailers used on public roads View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jon-Paul PRIGENT · 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
Jon-Paul Prigent died on 30 July 2020 when a soil-laden trailer decoupled from its tractor, overturned, and compressed the car in which he was sitting, causing asphyxiation. The principal concerns were the absence of periodic independent testing for agricultural tractors and trailers, the lack of required safety features to prevent decoupling, and the risks posed by worn, overloaded, and unevenly loaded equipment used on public roads.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure of current agricultural tractor and trailer safety arrangements to keep pace with changing road use
Wider context from the report “4. Tractors and trailers are increasingly large and carrying heavier loads due to farm consolidation and are correspondingly traveling further distances on public roads to reach more distant areas on larger farms, and agri-business depots and processing sites. The current safety arrangements have probably failed to keep up to date and relevant and were more suited to an era when agricultural use tractors and trailers might simply have been crossing a road to get form one field to another .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of periodic independent vehicle testing for tractors and trailers used on roads for agricultural purposes
Wider context from the report “1. Tractors and trailers driven on roads for ‘agricultural purposes’ are not subject to periodic independent vehicle testing . This places the responsibility for checking roadworthiness on the user which is clearly dependent on the diligence and competence of the user. It is therefore highly likely that some tractors and trailers are being driven on roads for ‘agricultural purposes’ in unroadworthy and unsafe condition , as was clear in Mr Prigent’s inquest.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to require safety features preventing decoupling of tractors and trailers used on public roads
Wider context from the report “2. Tractors and trailers driven on roads at below a speed of 25 miles per hour are not required to be fitted with safety features to prevent decoupling (e.g. a safety chain, or dual safe braking system) . Therefore, if decoupling occurs there is nothing to prevent independent and uncontrolled travel of the trailer .
3. Basic hitch hook and ring coupling systems for tractors and trailers are very simple and convenient for ease and speed of coupling and use on farms but present clear risk when used on public roads without safety features to prevent decoupling .
” 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 Publish and make freely available guidance on the safe selection, use, inspection and maintenance of agricultural machinery, including tractors and trailers.
Verbatim wording from the response “To help dutyholders comply with their legal duties regarding the use of agricultural machinery, including tractors and trailers, HSE has published a range of guidance which is freely available to download from our website. Guidance includes, but is not limited to:” Source location Response from HSE
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 Public-road vehicle testing, safety features and coupling requirements are matters for DVSA or other appropriate organisations.
Verbatim wording from the response “Periodic independent vehicle testing requirements specifically for tractors and trailers driven on the public road would be a matter for other organisations such as the DVSA to consider.” Source location Response from HSE
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 Use of agricultural vehicles on public roads falls outside HSE’s workplace health and safety enforcement remit.
Verbatim wording from the response “HSE are Britain’s national regulator for workplace health and safety, this includes use of work equipment such as vehicles in the workplace, but would not routinely include use of vehicles on public roads.” Source location Response from HSE
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 Dutyholders must assess agricultural machinery risks and implement reasonably practicable measures to control them.
Verbatim wording from the response “Health and safety legislation currently requires farmers to take reasonably practicable measures to control significant risk. Using suitable vehicles within their design parameters reduces the likelihood of unsafe conditions.” Source location Response from HSE
Open published response
25 Oct 2024 Wessam al Jundi · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Lack of adequate water suppression systems for dust created during artificial stone finishing View source Inadequate respiratory personal protective equipment for artificial stone finishing View source Absent or inadequate ventilation systems for artificial stone finishing View source Health surveillance failing to detect disease before it becomes untreatable View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wessam al Jundi · 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
Wessam al Jundi had severe silicosis and was admitted to Harefield Hospital on 17 May 2024 for a potential lung transplant, but was too unwell and died in hospital on 22 May 2024. The principal concern was that his untreatable lung disease was probably caused by workplace exposure to respirable crystalline silica from artificial stone products, in conditions described as unsafe and lacking adequate dust controls and respiratory protection.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate water suppression systems for dust created during artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created , in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Inadequate respiratory personal protective equipment for artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Absent or inadequate ventilation systems for artificial stone finishing
Wider context from the report “The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and their appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems . This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Health surveillance failing to detect disease before it becomes untreatable
Wider context from the report “Any current surveillance health and safety monitoring is unlikely to achieve a satisfactory outcome as the onset of untreatable disease predates the 15 year surveillance programmes. In this case exposure appears to have commenced in May 2016 and he was diagnosed with silicosis in 2021, a mere 5 years after initial exposure. Evidence from photographs and an in-life statement suggest Wessam was working in completely unsafe conditions to avoid dust exposure.
” 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 Publish guidance for installers, managers and supervisors on controlling exposure risks when working with high-silica-content stone.
Verbatim wording from the response “As part of this engagement, we have confirmed the requirements for working high silica content stone worktops, and we will shortly be publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. We are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks.” Source location Response from HSE
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 research into the underlying causes of employers’ poor compliance with control use.
Verbatim wording from the response “Collectively, this raises awareness of the need for controls when engineered stone is being worked. HSE continues to review the latest global evidence to consider what additional controls or action may be necessary and it is engaging with occupational lung disease clinicians to build understanding of affected workers. HSE has commissioned research to better understand the underlying causes of poor compliance with use of controls by employers closest to the problem (e.g. fabricators).” Source location Response from HSE
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 Confirm requirements for working high-silica-content stone worktops.
Verbatim wording from the response “As part of this engagement, we have confirmed the requirements for working high silica content stone worktops, and we will shortly be publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. We are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks.” Source location Response from HSE
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 Support development of an information leaflet with the Worktop Fabricators Federation for distribution through its networks.
Verbatim wording from the response “As part of this engagement, we have confirmed the requirements for working high silica content stone worktops, and we will shortly be publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. We are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks.” Source location Response from HSE
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 Publish updated supplementary guidance on health surveillance for workers exposed to respirable crystalline silica.
Verbatim wording from the response “Suitable health surveillance must also be provided for workers liable to be exposed to RCS. Where there is a risk of developing conditions such as accelerated silicosis, or where there is evidence of significant overexposure to RCS, the timing and performance of health surveillance should be adapted. This means chest x-rays being performed well before the 15-year time period you refer to, and referral to an occupational lung disease specialist being made as appropriate. In May 2024, we clarified these requirements in the updated ‘Health surveillance for those exposed to respirable crystalline silica (RCS), Supplementary guidance for occupational health professionals’, which is available on HSE’s website at https://www.hse.gov.uk/pubns/guidance/g404.pdf.” Source location Response from HSE
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 Investigate reported ill-health and concerns about inadequate risk management in industries with potential respirable crystalline silica exposure.
Verbatim wording from the response “HSE works with industry and suppliers to raise awareness of managing the risks of exposure to RCS, and works proactively with key stakeholders and trade associations, for example, in the construction industry. We have delivered several national inspection campaigns and continue to investigate reported ill-health and concerns about inadequate risk management in industries where there is potential for exposure to RCS.” Source location Response from HSE
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 Deliver national inspection campaigns addressing risks from respirable crystalline silica exposure.
Verbatim wording from the response “HSE works with industry and suppliers to raise awareness of managing the risks of exposure to RCS, and works proactively with key stakeholders and trade associations, for example, in the construction industry. We have delivered several national inspection campaigns and continue to investigate reported ill-health and concerns about inadequate risk management in industries where there is potential for exposure to RCS.” Source location Response from HSE
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 Meet stone-product manufacturers and fabrication employers to discuss practical controls for high-silica-content stone work.
Verbatim wording from the response “On 7 October 2024, we met with manufacturers of stone products to discuss practical solutions businesses and dutyholders can take to protect workers from exposure to RCS when working with high silica content stone. We also met with key fabrication employers on 25 November 2024. Further workshops are proposed to ensure a broad understanding of how engineered stone is being supplied and used to enable us to devise further interventions targeting key issues.” Source location Response from HSE
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 global evidence to determine whether additional controls or action may be necessary.
Verbatim wording from the response “Collectively, this raises awareness of the need for controls when engineered stone is being worked. HSE continues to review the latest global evidence to consider what additional controls or action may be necessary and it is engaging with occupational lung disease clinicians to build understanding of affected workers. HSE has commissioned research to better understand the underlying causes of poor compliance with use of controls by employers closest to the problem (e.g. fabricators).” Source location Response from HSE
Open published response
2 Aug 2024 Thomas Joseph McAuley · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of safety notices or wider publicity highlighting the risk of using the space between LGV rear axles View source Risk of fatal injury from using the space between LGV rear axles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Joseph McAuley · 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
Thomas Joseph McAuley died after being struck and catastrophically injured by a grab lorry while positioned between its axles during road resurfacing work. The report raises concerns that roadwork crews may continue using the space between LGV axles to urinate, creating a risk of fatal injury from vehicle movement, and that the risk may not have been communicated more widely.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of safety notices or wider publicity highlighting the risk of using the space between LGV rear axles
Wider context from the report “i. If the practice of using the space between the rear axles of an LGV is ongoing, there remains a risk of future deaths, as any small movement of the vehicle can cause fatal injuries. I am not aware of any safety notice(s) being issued since Mr McAuley’s death or any wider publicity that may have highlighted the risk. Ensuring that companies undertaking road resurfacing work or similar are made aware of the risk that this practice is ongoing will enable them to take measures to address this potential ongoing risk.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal injury from using the space between LGV rear axles
Wider context from the report “i. If the practice of using the space between the rear axles of an LGV is ongoing, there remains a risk of future deaths, as any small movement of the vehicle can cause fatal injuries. I am not aware of any safety notice(s) being issued since Mr McAuley’s death or any wider publicity that may have highlighted the risk. Ensuring that companies undertaking road resurfacing work or similar are made aware of the risk that this practice is ongoing will enable them to take measures to address this potential ongoing risk.
” 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 Continue raising awareness of welfare and construction-transport safety risks with industry through stakeholder engagement networks.
Verbatim wording from the response “Through our stakeholder engagement networks, we will continue to raise awareness of matters arising in this case with industry to ensure they manage them appropriately. These topics will also be raised at inspections where appropriate.” Source location Response from HSE
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 Publish freely accessible guidance on construction-site workplace transport safety, traffic management and pedestrian–vehicle segregation.
Verbatim wording from the response “HSE publishes guidance relating to workplace transport safety which is freely available on our website www.hse.gov.uk. The core message of this guidance being that duty holders must ensure that vehicle movements and traffic routes are organised such that pedestrians and vehicles are segregated so far as reasonably practicable. It is important to note that controls for transport safety cover segregation of pedestrians from vehicles whether moving or stationary, as unauthorised access to vehicles should be prevented and there are risks that stationary vehicles can move unexpectedly.” Source location Response from HSE
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 Existing legislation and guidance are considered sufficient to control welfare and construction transport risks.
Verbatim wording from the response “Having reviewed the circumstances of this fatal accident, it is HSE’s view that the need to provide adequate welfare facilities and control risks associated with transport safety are well known to industry and legislation and suitable and sufficient guidance already exists to assist duty holders in complying with their duties and adequately control the risks involved in this accident.” Source location Response from HSE
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 Duty holders retain responsibility for achieving legal compliance and sourcing advice suitable for their individual circumstances.
Verbatim wording from the response “The responsibility to achieve legal compliance, source suitable advice or information for their individual circumstance’s rests with the duty holder.” Source location Response from HSE
Open published response
18 Jul 2024 Tony WILLIAMS · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of clear visual guidance for drivers loading and unloading bales View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tony WILLIAMS · 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 2 December 2020, Tony Williams died at the scene after two hay bales fell on him while he was unloading an HGV in Cheshire. The report raised concern that guidance and support materials did not contain clear images to assist drivers loading and unloading bales.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of clear visual guidance for drivers loading and unloading bales
Wider context from the report “It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales .
” 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 Continue periodically reviewing HSE guidance on safe bale work, considering the report’s concerns at the next review.
Verbatim wording from the response “However we keep HSE guidance, including INDG125, under periodic review and we will keep your report on record for consideration when it is next reviewed.” Source location Response from HSE
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 Current guidance provides sufficient information for safely loading and unloading bales, so further images or supporting material are not currently required.
Verbatim wording from the response “In relation to the safe loading and unloading of bales, the principles are set out throughout the guidance document but specifically on pages 6 and 7. We acknowledge the absence of images in this section however, having considered the concerns raised in your report we have concluded that there is sufficient information that will allow duty holders to plan and carry out the loading and unloading of bales safely and that the current guidance is satisfactory.” Source location Response from HSE
Open published response
13 Jun 2024 Graham FAULKNER · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 4 Investigation selection criteria failing to include paraplegia injuries View source Failure to conduct prompt investigations of serious workplace incidents View source Investigation selection criteria failing to include RIDDOR 4(2) incidents View source Lack of discretionary investigation-selection criteria for incidents warranting investigation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Graham FAULKNER · 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
Graham Faulkner was exposed to caustic soda at work in October 2015, later developed paraplegia, and died in 2019 from sequelae of the injury. The principal concern was that the HSE did not promptly investigate the incident, resulting in evidence being unavailable or delayed and making it harder to establish the facts and learn from the death. The inquest conclusion also referred to failures in the administration and management of the Permit to Work process and a lack of challenge around PPE.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Investigation selection criteria failing to include paraplegia injuries
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate. Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia , given the life changing severity of such injuries .
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prompt investigations of serious workplace incidents
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate . Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia, given the life changing severity of such injuries.
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Investigation selection criteria failing to include RIDDOR 4(2) incidents
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate. Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia, given the life changing severity of such injuries.
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of discretionary investigation-selection criteria for incidents warranting investigation
Wider context from the report “Summary: The absence any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
The incident occurred on 15 October 2015. The employer became aware of the incident shortly after 22 October 2015, but initially had limited details.
The HSE were informed of the incident in early November 2015. The RIDDOR report to the HSE noted "Injury preventing the injured person from working for more than 7 days". Separate email correspondence to the HSE at around the same time informed the HSE that Mr Faulkner was in the ICU.
By 4 November 2015, Mr Faulkner had developed paraplegia from the consequences of his initial injuries.
Despite it being known to the HSE that Mr Faulkner had suffered some form of injury with serious consequences (ie ICU admission), the HSE did not investigate. Their records do not show a specific reason for this, but I am informed it did not meet the selection criteria.
The selection criteria are dated 2014 and are still in place today.
These 2014 criteria include incidents which engage the reporting requirements in RIDDOR 4(1). None of these criteria apply to Mr Faulkner.
The investigation criteria does not include the criteria in RIDDOR 4(2) - namely "Where any person at work is incapacitated for routine work for more than seven consecutive days (excluding the day of the accident) because of an injury resulting from an accident arising out of or in connection with that work, ...."
It is unclear why the 2014 selection criteria apply to RIDDOR 4(1) and not to 4(2), when both engage statutory reporting criteria.
It is unclear why the criteria in RIDDOR 4(1) do not include injuries resulting in paraplegia, given the life changing severity of such injuries.
If the reason the 2014 selection criteria are relatively narrowly drafted is to avoid excessive expansion of the HSE's duties, it is unclear why there is not a "discretionary" criteria which would allow for investigations where the known facts would suggest that an investigation would be appropriate in accordance with the HSE's wider statutory functions and purpose.
As a result of the HSE decision not to investigate in 2015, various evidence was either not obtained or is no longer in existence. The first witness statement accounts from many eye witnesses date to 2021 or 2022 - some 5 years or more after the events in question.
This has meant that it is challenging to establish the facts that led to Mr Faulkner's injury. Issues that have been in dispute in the evidence have included when the exposure took place, where it took place, the PPE he was wearing and the instructions as to PPE on the permit to work. It is likely that many of these issues would be factually clear(er) if evidence had been obtained in 2015, shortly after the incident, when memories were fresher and various paperwork still in existence.
The absence of any or any prompt investigation by the HSE to establish the relevant facts and potential gaps in process could have an impact upon the ability to learn from one death and so avoid other deaths.
” 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 Consider specifically naming paraplegia in the Incident Selection Criteria at the next review.
Verbatim wording from the response “HSE guidance is reviewed to reflect emerging issues and concerns in response to learning and recommendations following incidents. Reviewing our ISC approach has been a recent area of work for HSE and we are moving away from selecting incidents by harm outcome and instead selecting by risk. So although I have passed your suggestion for ‘paraplegia’ to be specifically named in the ISC to HSE’s policy team for consideration at the time of the next ISC review, it is likely that we will focus more in future on risk rather than injury.” Source location Response from Health and Safety Executive
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 Train staff to apply the Incident Selection Criteria pragmatically and obtain managerial advice when its application is uncertain.
Verbatim wording from the response “However, I can assure you that the Principal Inspectors who are reviewing such RIDDOR reports would not hesitate to consider paraplegia as being a severe injury just because it is not specifically listed. Our staff are trained to be pragmatic in the application of the ISC to ensure that we respond where appropriate to serious injury incidents and are not restricted solely by examples. HSE staff can seek advice from line managers should they be unsure of ISC application and regularly do so.” Source location Response from Health and Safety Executive
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 Move Incident Selection Criteria review and incident prioritisation from harm-outcome selection toward risk-based selection.
Verbatim wording from the response “HSE guidance is reviewed to reflect emerging issues and concerns in response to learning and recommendations following incidents. Reviewing our ISC approach has been a recent area of work for HSE and we are moving away from selecting incidents by harm outcome and instead selecting by risk. So although I have passed your suggestion for ‘paraplegia’ to be specifically named in the ISC to HSE’s policy team for consideration at the time of the next ISC review, it is likely that we will focus more in future on risk rather than injury.” Source location Response from Health and Safety Executive
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 Omission of paraplegia from listed categories does not prevent staff from treating it as a severe injury and considering investigation.
Verbatim wording from the response “However, I can assure you that the Principal Inspectors who are reviewing such RIDDOR reports would not hesitate to consider paraplegia as being a severe injury just because it is not specifically listed. Our staff are trained to be pragmatic in the application of the ISC to ensure that we respond where appropriate to serious injury incidents and are not restricted solely by examples. HSE staff can seek advice from line managers should they be unsure of ISC application and regularly do so.” Source location Response from Health and Safety Executive
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 The Incident Selection Criteria already permits investigation of any RIDDOR incident indicating a likely serious breach, including Regulation 4(2) notifications.
Verbatim wording from the response “There is more information about the ISC’s application within HSE Investigation Procedure which is also publically available at Investigation - Stage 2: Decide whether to investigate (hse.gov.uk). The ISC is focussed on RIDDOR reports under Regulation 4(1) to ensure highest injury type incidents are prioritised for investigation consideration. However, the ISC also includes an option at section 4 which allows for any type of RIDDOR to be considered for investigation should it indicate a likelihood serious breach of health and safety law. Thus our view is that the ISC already has the type of flexibility you are suggesting to help learn lessons from incidents where standards are far from where they should be, including linked to a Reg 4(2) notification.” Source location Response from Health and Safety Executive
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 A meaningful investigation could not be conducted because too much time had passed and key evidence was unavailable.
Verbatim wording from the response “We also considered whether there was any realistic possibility of conducting an investigation at that time in 2019, however concluded that unfortunately too much time had passed meaning key evidence was unavailable to be able to conduct a meaningful investigation. We updated both the Police and Coroner’s Office of that decision at that time. We also updated Mr Faulkner’s next of kin and more recently met them jointly with the Police, ahead of the inquest, to further respond to their questions.” Source location Response from Health and Safety Executive
Open published response
Concerns raised 17 Failure to require safety-training reference material View source Superficial and inadequate safety training View source Lack of independent periodic auditing and inspection View source Failure to impose and define effective restricted duties View source Failure to complete a timely Fatal Accident Inquiry Panel investigation View source Lack of robust training-compliance monitoring and responsibility clarity View source Delays and gaps in mandatory training completion View source Failure of central oversight of local safety execution View source Failure to ensure permit-holder competence and permit-scope clarity View source Failure to plan and provide appropriate first aid kits View source Failure to communicate death-related learning to coroners View source Lack of a culture of candour View source Failure to verify supplementary first-aid learning View source Insufficient safety-team resources and local reach View source Appointment of leaders without suitable competence or qualifications View source Insufficient Local Training Manager capacity View source Overly discretionary validation of inadequate training View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Benjamin David Leonard · 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
Benjamin David Leonard, aged 16, died after slipping and falling from a cliff while descending the Great Orme during an Explorer Scout trip in North Wales. The report identifies concerns about inadequate planning, risk assessment, briefing, supervision, training, safeguarding, first-aid provision, oversight and the Scouts Association’s response to the 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. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to require safety-training reference material
Wider context from the report “13. Whilst reference material is available in the course, it is not mandatory reading and not required in order to complete the click through course.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Superficial and inadequate safety training
Wider context from the report “12. Safety training is predominantly done online. Having seen and forensically within the hearing, undertaken an exercise to complete the current Safety Module, I am concerned that the course is superficial at best and fundamentally basic . It can be completed in 12 minutes . It is unsurprising that the current pass rate is now correspondingly high. This causes concern as an introductory module needed to equip thousands of leaders with an understanding of how to complete a risk assessment in order to keep Scouts safe. It does not embed the fundamental principles of safety and safe scouting .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of independent periodic auditing and inspection
Wider context from the report “2. I am also concerned that, whilst the Charity Commission has regulatory oversight, there is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scouts Association or the granting of permits for adventurous activities, hill walking and Nights Away permits. Further, The Scouts Association permit scheme for adventurous activities is exempt from regulation by the Health and Safety Executive (‘HSE’).
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to impose and define effective restricted duties
Wider context from the report “14. There was a plain reluctance to prioritise the safety of young people following Ben’s death in that, the leaders ████████ were not subjected to “Restricted Duties” until 17.10.18 when Ben had died on 26.8.18 and in the time from Ben’s death, ████████ had taken part in a camp called “Deep Heat”. POR (Policy, Organisation and Rules) indicated the neutral act of suspension should have been imposed as a minimum for ████████. Once the restricted duties were issued, there was confusion as to whether these related to individuals or specific activities and at least one of the leaders continued in their Scouting obligations with no restrictions as it related to “Scouts” rather than “Explorer Scouts” and so the restrictions were ineffective .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a timely Fatal Accident Inquiry Panel investigation
Wider context from the report “4. As of 22.2.24, over 5 years since Ben’s death there is still no Fatal Accident Inquiry Panel Report in existence . Further still, even the prospective panel members for this investigation have not been identified . A document I have received entitled ‘BL Great Orme Learning and Actions Update’ dated 30.9.19 is inadequate when considering the root and branch type of review needed following a child fatality to identify and address issues of safety and safeguarding – particularly these having been identified as significant issues on the day of Ben’s death and despite this fact – no investigation followed -with The Scouts Association maintaining this was due to a live police investigation initially, and latterly due to this inquest.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of robust training-compliance monitoring and responsibility clarity
Wider context from the report “20. I have heard evidence that The Scouts Association headquarters maintain that it is for the County and District as autonomous charities to monitor and audit training compliance. I am concerned that there are not robust systems of analysis, reporting and clarity as to the responsibilities of the County and District and what The Scouts Association require from the County and District in respect of:
i. Training compliance;
ii. Completion of induction training within 5 months;
iii. Completion of the full adult training scheme/ wood beads within 2 years;
iv. Appointment to roles – both pre provisional, provisional, and full appointment;
v. Granting of permits.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Delays and gaps in mandatory training completion
Wider context from the report “29. These statistics lead to the clear conclusion that there were widespread and significant gaps in training being completed in a timely manner , with concerns surrounding the training provision in the Stockport District.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure of central oversight of local safety execution
Wider context from the report “36. The Scouts Association is distant from its membership through its federated branches of 8000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level . Training and POR are generated centrally, yet The Scouts Association defer accountability for safeguarding and safety to the individual charities .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure permit-holder competence and permit-scope clarity
Wider context from the report “38. The example of ████████ having been granted his Nights Away permit simply by providing a list of camps he had been on, demonstrates that there was no robust system in place to ensure that a permit holder responsible for children’s safety was suitably qualified . There is no evidence he had the necessary skills and competencies to be granted such a permit. There was also a lack of clarity on where permits would be required for activities outside of the ordinary Scouts meeting place.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and provide appropriate first aid kits
Wider context from the report “32. I did not receive any evidence to suggest that, following an appropriate risk assessment for the Great Orme trip, there was a plan as to what type of first aid kit was required . None of the leaders had a first aid kit with them when they embarked on the walk up the Great Orme or on a 3-hour hike on the Saturday.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate death-related learning to coroners
Wider context from the report “11. I therefore have concerns that not all matters regarding deaths connected with the Scouting Movement and Association are being communicated , even by provision of draft report and recommendations, to His Majesty’s Coroners of England and Wales to inform PFD issues and a Coroner’s PFD reporting duties.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within The Scouts Association (‘TSA’) and the impact that this has on safety and safeguarding.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to verify supplementary first-aid learning
Wider context from the report “34. There was a system in place whereby if a learner had a first aid at work certificate, they could self-certify that they had undertaken further learning, for Child CPR, hypothermia and meningitis to comply with Module 10 First Response. There were no checks to ensure that this further learning had been done, nor was it assessed .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety-team resources and local reach
Wider context from the report “37. The centralised safeguarding team and safety team are not on par with each other in terms of resources and reach to local level . Safety is not prioritised in the same way as safeguarding has been . Safeguarding is reacted to more quickly than safety by The Scouts Association.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Appointment of leaders without suitable competence or qualifications
Wider context from the report “19. This gives rise to a concern that there are other appointed Leaders in post who are not suitably competent or qualified in respect of the fundamental issues of safety and safeguarding.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient Local Training Manager capacity
Wider context from the report “31. I am concerned by evidence at the inquest that, presently, Stockport only has 6 Local Training Managers in post where 9 are required . The remaining 3 are “awaiting appointment” .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Overly discretionary validation of inadequate training
Wider context from the report “23. For Local Training Managers (‘LTM’) a process for validation exists whereby a training adviser interprets the Training Advisers Guide and has a broad scope within which they can validate a learner’s training . This creates a risk of the approval of superficial and inadequate learning .
” 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 Investigate Ben’s death under the Work-related Death Protocol to determine its cause, identify lessons and prevention actions, and take appropriate enforcement action.
Verbatim wording from the response “Our Investigation Division have now begun an investigation into Ben’s death in accordance with the Work-related Death Protocol to determine the cause, identify lessons and actions needed to prevent any recurrence and take appropriate enforcement action. I have asked the team to ensure the investigation is given priority, given the unacceptable delays that have already occurred.” Source location Response from Health and Safety Executive
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 how the investigation error occurred and identify measures to prevent it recurring.
Verbatim wording from the response “The error in not identifying, repeatedly, that this was a matter for HSE to investigate was clearly unacceptable and I would like to apologise to Ben’s parents and family that an investigation has not been undertaken sooner. HSE will undertake an appropriate review to identify how this error occurred, and to ensure that it is not repeated. We also will be writing directly to Ben’s family to offer them an apology.” Source location Response from Health and Safety Executive
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 Scouting activities are exempt from Adventure Activities Licensing, but not from wider Health and Safety Executive regulation or oversight.
Verbatim wording from the response “In your report you have noted that, in your opinion, action should be taken to prevent future deaths. Whilst you have referred your report to a number of parties, you have raised two main areas of concern that appear to fall to HSE to address: that there is no independent or robust regulator who independently and proactively audits and inspects the Scout Association’s arrangements for adventurous activities and that these activities are otherwise exempt from regulation by the Health and Safety Executive (HSE). Whilst more detail is provided in this response, I would highlight here that, whilst it is true that the Scout Association is exempt from regulation by HSE’s Adventure Activities Licensing Authority, as are all voluntary associations providing services to their own members, it is not correct that this equates to a wider exemption from all HSE regulation and oversight.” Source location Response from Health and Safety Executive
Open published response
8 Nov 2023 Owen Paul Garnett · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 6 Lack of staff guidance on identifying health and safety concerns View source Failure to act on carers’ health and safety concerns View source Lack of clarity about the timing and responsibility for reviewing plan implementation View source Retrospective feedback on prioritising supervision View source Lack of arrangements for carers to participate in and challenge the concerns process View source Unclear circumstances for deviating from planned supervision View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Owen Paul Garnett · 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
Owen Garnett, a 19-year-old student with severe learning difficulty, swallowing problems and Pica, died after choking on a significant amount of blue paper towel while unsupervised at school. The principal concerns were that carers’ repeated concerns were not acted on, that required supervision was not provided despite the risk assessment, and that the school’s subsequent action plan lacked clear guidance and oversight.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of staff guidance on identifying health and safety concerns
Wider context from the report “1. The evidence showed that the concerns of Owen’s carers were not acted on. Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers. The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to act on carers’ health and safety concerns
Wider context from the report “1. The evidence showed that the concerns of Owen’s carers were not acted on . Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers . The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the timing and responsibility for reviewing plan implementation
Wider context from the report “3. The Health and Safety Inspector present at the inquest indicated that the Inspectorate had not had the opportunity to review the plan and would be considering whether to participate further by reviewing the implementation of the plan. However, as the relevant inspector could not be present, it was unclear when the plan could be reviewed and by whom .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Retrospective feedback on prioritising supervision
Wider context from the report “2. Had Owen been supervised as envisaged in his risk assessment, he would not have been able to consume the significant quantities of blue paper towel found in his mouth and throat. The class teachers’ evidence was that after her initial training, the process of advice on prioritising of supervision was retrospective in that she only received feedback on events that had already occurred . The current plan appears to permit the class teacher to deviate from the planned supervision and prioritising of supervision in circumstances that are not made clear.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements for carers to participate in and challenge the concerns process
Wider context from the report “1. The evidence showed that the concerns of Owen’s carers were not acted on. Evidence was given that had the school seen the photographs they would have been more likely to have reacted to the information, but less weight was placed on an oral report by carers. The new plan seems to recognise that carers’ concerns should be acted upon by recording as a near miss incident any health and safety concerns and these should be reviewed. It appears that the decision to regard any such concerns as relating to health and safety and then record the concerns can be made at class staff level. There is no guidance as to what should or should not be regarded as a health and safety concerns by staff. There is no guidance as to how carers will be assisted to participate in this process or what steps can be taken by carers who feel their concerns have been disregarded .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Unclear circumstances for deviating from planned supervision
Wider context from the report “2. Had Owen been supervised as envisaged in his risk assessment, he would not have been able to consume the significant quantities of blue paper towel found in his mouth and throat. The class teachers’ evidence was that after her initial training, the process of advice on prioritising of supervision was retrospective in that she only received feedback on events that had already occurred. The current plan appears to permit the class teacher to deviate from the planned supervision and prioritising of supervision in circumstances that are not made clear.
” Open source report
31 Oct 2023 Evelyn Ann Burcham · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 4 Unavailability of riser-recliner chairs with controls that limit unauthorised use View source Failure to assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls View source Health and safety risk from disabling riser-recliner chair controls at the mains View source Risk of death to other residents from cognitively impaired residents operating riser-recliner chair controls View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Evelyn Ann Burcham · 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
Evelyn Ann Burcham, who had dementia and required full care, was tipped from a riser-recliner chair after another resident accessed and operated its remote control while it was unattended. She sustained a severe brain bleed and died ten days later. The principal concern was that the risk of cognitively impaired residents accessing and operating chair controls had not been foreseen, and that the chairs lacked a suitable safety feature to restrict access to the controls.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Unavailability of riser-recliner chairs with controls that limit unauthorised use
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Health and safety risk from disabling riser-recliner chair controls at the mains
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Risk of death to other residents from cognitively impaired residents operating riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” 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 Notify the Office for Product Safety and Standards about the incident for consumer-product safety consideration.
Verbatim wording from the response “After receiving your report, HSE contacted the other regulatory bodies who may have an interest or potential regulatory role in respect of this incident. We have written to CQC (who are already in receipt of your report) on the patient safety aspects. HSE has also notified the Office for Product Safety and Standards (OPSS) who are the national regulator for consumer products and who work with the local authority Trading Standards services that undertake most enforcement activity.” Source location Response from Health and Safety Executives
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 Consumer-product safety enforcement for chairs purchasable for domestic use normally falls to local-authority Trading Standards, not HSE.
Verbatim wording from the response “With regard to product safety matters, the chair involved in this tragic incident would appear to meet the definition of a ‘machine’, and therefore the relevant supply legislation would be the Supply of Machinery (Safety) Regulations 2008, which implemented the EU Machinery Directive 2006/42/EC in GB.” Source location Response from Health and Safety Executives
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 CQC is responsible for regulating safety, treatment and care matters involving service users in registered care homes.
Verbatim wording from the response “In England, the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents in the health and adult social care sectors.” Source location Response from Health and Safety Executives
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 Service-user safety enforcement in registered care homes is outside HSE’s remit.
Verbatim wording from the response “In England, the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents in the health and adult social care sectors.” Source location Response from Health and Safety Executives
Open published response
4 Oct 2023 Kellie Jean POOLE · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 11 Insufficient training and experience of cold water immersion session leaders View source Lack of specific health and safety guidance for cold water immersion providers View source Lack of pre-session health advice or warnings for cold water immersion participants View source Lack of written risk assessments for cold water immersion sessions View source Lack of guidance from the Health and Safety Executive or other appropriate bodies for cold water immersion activities View source Lack of voluntary self-regulation for cold water immersion providers View source Unclear local authority environmental health monitoring and oversight of cold water immersion providers View source Lack of adequate first aid training and equipment for cold water immersion sessions View source Risk posed by open-water locations used for cold water immersion sessions View source Lack of regulation or quality assurance of cold water immersion leader training View source Lack of public liability insurance among cold water immersion providers View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kellie Jean POOLE · 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
Kellie Jean POOLE died on 25 April 2022 after collapsing during a led cold water immersion session in the River Goyt. The report states that cold water likely triggered a heart rhythm disturbance and that she had an abnormal heart. The principal concerns were the limited oversight and regulation of cold water immersion providers, including health warnings, safety measures, leader training, first aid provision, insurance, risk assessments and guidance from relevant authorities.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and experience of cold water immersion session leaders
Wider context from the report “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader , first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of specific health and safety guidance for cold water immersion providers
Wider context from the report “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-session health advice or warnings for cold water immersion participants
Wider context from the report “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings , public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of written risk assessments for cold water immersion sessions
Wider context from the report “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment, or written risk assessments . I am not aware of the issuing of specific health and safety guidance.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance from the Health and Safety Executive or other appropriate bodies for cold water immersion activities
Wider context from the report “On my understanding the current limits of oversight of cold water immersion providers in effect means that these activities have not received guidance from the Health and Safety Executive or other appropriate bodies . My investigation indicated that local authority environmental health departments are unclear whether they should and how they might monitor and oversee these providers.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of voluntary self-regulation for cold water immersion providers
Wider context from the report “There is no established UK member organisation for providers of cold water immersion , other than for ‘wild’ and open water swimming which is a distinct activity, and therefore no form of even voluntary self-regulation .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Unclear local authority environmental health monitoring and oversight of cold water immersion providers
Wider context from the report “On my understanding the current limits of oversight of cold water immersion providers in effect means that these activities have not received guidance from the Health and Safety Executive or other appropriate bodies. My investigation indicated that local authority environmental health departments are unclear whether they should and how they might monitor and oversee these providers .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate first aid training and equipment for cold water immersion sessions
Wider context from the report “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance, training and experience of the session leader, first aid training and equipment , or written risk assessments. I am not aware of the issuing of specific health and safety guidance.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Risk posed by open-water locations used for cold water immersion sessions
Wider context from the report “Some sessions take place in water tanks, but sessions are also held in open water such as rivers, lakes, and reservoirs, and therefore at locations that may in themselves pose risk . Session leaders may have undertaken some form of training, but I am not aware that the nature and quality of the training itself is regulated/quality assured.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation or quality assurance of cold water immersion leader training
Wider context from the report “Some sessions take place in water tanks, but sessions are also held in open water such as rivers, lakes, and reservoirs, and therefore at locations that may in themselves pose risk. Session leaders may have undertaken some form of training, but I am not aware that the nature and quality of the training itself is regulated/quality assured .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of public liability insurance among cold water immersion providers
Wider context from the report “There seems to be very little oversight of these businesses in their provision of cold water immersion covering matters such as pre-session health advice or warnings, public liability insurance , training and experience of the session leader, first aid training and equipment, or written risk assessments. I am not aware of the issuing of specific health and safety guidance.
” 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 legal requirements and guidance from multiple authoritative sources are considered sufficient, so HSE will not publish specific cold water immersion guidance now.
Verbatim wording from the response “well as targeted guidance for higher-risk industries and activities. HSE does not seek to provide guidance for all industries and activities as it is often the case that others are more knowledgeable or better placed to provide such guidance.” Source location Response from Health and Safety Executive
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 Local authorities are predominantly responsible for enforcing work-related health and safety legislation for cold water immersion activities.
Verbatim wording from the response “HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area. To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm).” Source location Response from Health and Safety Executive
Open published response
7 Jul 2023 David Alan LYTH · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of regular and periodic training for all drivers in coupling and uncoupling procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Alan LYTH · 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 30 November 2021, David Alan Lyth became trapped between two HGV trailers while coupling a new trailer, and his death was confirmed at hospital. The inquest concluded that he died from asphyxia after the trailers rolled away. The principal concern was the provision of regular and periodic training for all drivers on coupling and uncoupling procedures, following evidence of four rollaway incidents involving drivers at 3D Trans Ltd since 2020.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of regular and periodic training for all drivers in coupling and uncoupling procedures
Wider context from the report “(1) I received evidence that since 2020, there have been four rollaway incidents involving drivers working for 3D Trans Ltd:-
a. An incident causing damage to a fence between the 17th September 2020 and the 9th October 2020;
b. An incident leading to the death of Mr Lyth on the 30th November 2021;
c. An incident on the 15th November 2022;
d. An incident on the 12th June 2023.
I acknowledge that these incidents involve different circumstances and that only one resulted in a fatality.
(2) I received evidence that following each of the incidents, refresher training was provided and various measures were put in place at the yard to physically prevent the vehicles or trailers rolling away. In addition to this, signage has been placed on the tractor and trailer units to serve as a reminder to drivers of the importance of securing the parking brakes on the tractor and trailer units. I have concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures.
” 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 Produce and provide cross-industry workplace transport guidance covering practical coupling and uncoupling safety measures.
Verbatim wording from the response “HSE produced further guidance on transport safety in 2014; this guidance is aimed at all industries and also provides practical measures for coupling and uncoupling, please see Workplace transport safety - A guide to workplace transport safety (hse.gov.uk)” Source location Response from HSE
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 Produce and provide industry-specific guidance on managing coupling and uncoupling risks for articulated vehicles.
Verbatim wording from the response “To assist employers with that process, HSE produces extensive free guidance on managing risk, some of which is industry specific. For example, HSE worked closely with the haulage industry and other regulators to investigate the reasons for unintended vehicle movement and subsequently produced specific guidance in 2013, please see safe-coupling-guide.pdf. This guidance provides practical advice for employers to help them manage the risks of coupling and uncoupling articulated vehicles.” Source location Response from HSE
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 Employers are responsible for deciding refresher-training intervals based on risks specific to their businesses.
Verbatim wording from the response “As part of their consideration of risk in the business, employers should identify suitable risk controls and provide appropriate training and information to their employees to enable them to carry out their jobs safely, as well as an appropriate level of supervision/review to ensure that processes are followed consistently and that any issues are quickly identified and resolved. It is, for this reason, the employer’s responsibility to decide on the intervals for any refresher training. Whatever system the employer chooses to implement to manage risk, they should review it regularly to make sure it is up to date and still relevant.” Source location Response from HSE
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 Existing training, monitoring and supervision measures for 3D Trans drivers are considered sufficient for safe coupling and uncoupling.
Verbatim wording from the response “In relation to 3D Trans Ltd, HSE has conducted a further Inspection of the company since the inquest, and we are satisfied with the measures the company have put in place regarding training and monitoring and supervision for their drivers in respect of safe coupling and uncoupling procedures.” Source location Response from HSE
Open published response
22 May 2023 Karl Mitchell · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Continued use of unmodified lorry mounted cranes with crush injury risks View source Failure to ensure operators are aware of crush injury risks View source Failure to ensure operators are aware of available safety modifications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Karl Mitchell · 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
Karl Mitchell, a lorry driver, was crushed by a rotating stabilising leg while retracting a stabiliser beam during the delivery of a container on 23 September 2021. He was taken to hospital and died from his injuries on 25 September 2021. The report raises concerns that many unmodified lorry-mounted cranes remain in use and that operators may be unaware of available safety modifications and the risk of crushing.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Continued use of unmodified lorry mounted cranes with crush injury risks
Wider context from the report “(1) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry
(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner / operator of the vehicle becomes aware of possibility of modifications being available.
(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.
(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure operators are aware of crush injury risks
Wider context from the report “(1) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry
(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner / operator of the vehicle becomes aware of possibility of modifications being available.
(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.
(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure operators are aware of available safety modifications
Wider context from the report “(1) There are a large number of these lorry mounted cranes with such stabiliser beams and rotating legs in use by companies of all sizes and for a variety of uses within the industry
(2) Whilst manufacturers have taken steps to modify the design of the stabiliser beams and rotating legs so as to ensure the risk of such crush injuries can be avoided in the future such modifications will only apply to new vehicles and those where the owner / operator of the vehicle becomes aware of possibility of modifications being available.
(3) Vehicles without being modified will continue to be used throughout the industry and thereby such vehicles will continue to pose a risk of crush injuries occurring to the operator.
(4) Action needs to be taken to disseminate the learning from this tragic incident throughout the industry so that operators of such vehicles are aware that safety modifications may be available for their vehicle and in any event operators need to be made aware of the risk of crushing so as to ensure safe operation at all times.
” Open source report
16 Mar 2023 John Anthony IBBOTSON · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 3 Lack of information passed down the supply chain about the supply and use of single-deck pallets View source Lack of awareness of relevant standards for stacking single-deck pallets View source Failure to label pallets to indicate whether they are single-deck pallets for stacking purposes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
John Anthony IBBOTSON · 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
John Anthony Ibbotson, a 57-year-old warehouse operative, was found at work with a pallet on top of his back on 21 September 2020 and was pronounced dead shortly afterwards. The inquest heard that pallets were more likely than not double stacked directly on top of one another, although it was unclear what caused the pallet to fall. Concerns included limited awareness of relevant pallet-stacking standards, insufficient information passed through the supply chain, the absence of labelling for single-deck pallets, and training that did not include the prohibition on stacking them.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of information passed down the supply chain about the supply and use of single-deck pallets
Wider context from the report “2. The lack of information that is presently passed down the supply chain as to the supply and use of the ‘single deck’ pallets .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of relevant standards for stacking single-deck pallets
Wider context from the report “1. There was a lack of awareness of the content of the relevant British Standards, European Standards and International Standards as they relate to the stacking of single deck pallets .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to label pallets to indicate whether they are single-deck pallets for stacking purposes
Wider context from the report “Single deck pallets
Pallets are not currently labelled to indicate whether they should be stacked as a single- deck pallet .
” Open source report
9 Mar 2023 Mr Tomas Ceida · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to follow up non-receipt of a building application View source Lack of assurance that fire safety and evacuation responsibilities are competently adopted and implemented View source Lack of communication with fire enforcement during site construction and events View source Failure to notify London Fire Brigade of a material discrepancy from the planning application View source Lack of public and future contractor awareness of fire precaution processes and duties View source Failure to create or retain documentation of changes in contractor and site manager roles View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Tomas Ceida · 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
Mr Tomas Ceida died in hospital after a fire at a site being used as a nightclub, where construction work was underway and staff and operatives sometimes slept overnight. The jury identified concerns including the unsuitable acoustic wall, unsafe and inadequately supervised hot works, and failures to agree and communicate fire-safety responsibilities, provide adequate fire alerts, conduct an orderly evacuation, and complete adequate fire-risk assessments. The coroner also raised concerns about regulatory follow-up, communication between authorities, documentation of contractor roles, and public and contractor awareness of fire-safety duties.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up non-receipt of a building application
Wider context from the report “• RLBG Building Control were aware of the composition of the acoustic wall compacted with hay or straw, and its fire risks and did not follow up the non-receipt of a building application after March 2013 .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance that fire safety and evacuation responsibilities are competently adopted and implemented
Wider context from the report “• Although steps were taken by JHS to mitigate fire risks through the subsequent management and supervision of hot works, there is no evidence of what steps are taken by JHS individuals now in the building trade in each case to ensure the responsibility for fire safety and evacuation has been competently adopted and implemented .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of communication with fire enforcement during site construction and events
Wider context from the report “• LFB visited the site in 2014 and the local team attended large night club events on the site, during construction from 2016, but there was no communication with fire enforcement
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to notify London Fire Brigade of a material discrepancy from the planning application
Wider context from the report “• RLBG Planning Division did not notify London Fire Brigade in 2016 when discovered that the wall was not a living wall as envisaged in the planning application .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of public and future contractor awareness of fire precaution processes and duties
Wider context from the report “• It is understood that changes in the law and duties of securing general fire precautions has changed since the fire. It is not clear that the public and future contractors are necessarily aware of the processes and duties. The coroner is concerned whether there is a lack of public awareness, which may be a risk to future deaths. This is brought to the attention of the HSE and LFB as enforcement authorities.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to create or retain documentation of changes in contractor and site manager roles
Wider context from the report “• JHS were initially documented as principal contractor and its subcontractor as site manager in 2016, but either did not create or did not retain documentation of the alleged change of role before the date of the fire , from discussions with the leaseholder of the site, who was the client.
” Open source report
17 Feb 2023 Jamie Paul Woods · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 4 Use of weaker methods for securing pre-cast concrete panels to vertical RSJs View source Lack of understanding of the importance of secure panel fixings View source Failure of inspections to identify weaker panel fixings View source Failure to ensure safe fastening of moved pre-cast concrete panels to vertical RSJs View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Paul Woods · 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
Jamie Paul Woods, a farm worker, died at the scene on 30 January 2021 after an upper pre-cast concrete panel came away from its fixing and caused multiple injuries. Concerns included the use of weaker fixings, insufficient recognition of the associated risks during farm inspections, and a lack of understanding among farm workers about securing such panels safely.
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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Use of weaker methods for securing pre-cast concrete panels to vertical RSJs
Wider context from the report “1. The sections of box tubing used to secure one end of the concrete panels to the vertical RSJ was a weaker method of securing the concrete panels in place , as compared to the method typically used (securing the panel directly to the RSJ using metal brackets bolted to the rear of the panel). They had been in place for a number of years and would have appeared to have been present when Hawkins Farm was subject to inspections by outside agencies, yet no remedial action was required .
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the importance of secure panel fixings
Wider context from the report “ii. There appears to be a lack of understanding of the importance of securing the panels in the optimal manner . It does not appear to have been understood by those working on the farm that the fixings that were used on the panel that collapsed were weaker , neither does it appear to have been appreciated by those that undertook inspections of the farm subsequent to the use of this weaker method of fixing. Publicising the risks and educating the farmers of the risks of departing from the recognised method of fixing the pre-cast concrete panels may reduce the risk of future deaths.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure of inspections to identify weaker panel fixings
Wider context from the report “ii. There appears to be a lack of understanding of the importance of securing the panels in the optimal manner. It does not appear to have been understood by those working on the farm that the fixings that were used on the panel that collapsed were weaker, neither does it appear to have been appreciated by those that undertook inspections of the farm subsequent to the use of this weaker method of fixing . Publicising the risks and educating the farmers of the risks of departing from the recognised method of fixing the pre-cast concrete panels may reduce the risk of future deaths.
” 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 Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe fastening of moved pre-cast concrete panels to vertical RSJs
Wider context from the report “i. Pre-cast concrete panels are likely extensively used across farms throughout England and Wales. The equipment required to move panels between buildings is likely to be available on the majority of farms, meaning that there is a significant risk that farm owners/workers will move panels if necessary without the need to refer to external trades/professionals . As a consequence, there is a risk of the panels subsequently being fastened to vertical RSJs in a less secure manner , as occurred on Hawkins Farm. A collapsing concrete panel poses a clear risk of death, given their weight.
” 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 Promoted information on building integrity, safe maintenance and periodic structural checks through agricultural safety stakeholder networks.
Verbatim wording from the response “The HSE engages with a wide range of industry stakeholder and intermediaries to promulgate key messages and increase the awareness of the risks to health and safety in Agriculture. One part of this work is the distribution of timely messages following incidents. In February 2021 the HSE’s national agriculture team promoted information relating to building integrity through the Farm Safety Partnership (FSP*) chairs and Agriculture Industry Advisory Committee (AIAC**) members. This included the need to keep farm buildings in a safe condition and properly maintained and the importance of periodic structural checks The FSPs have a rolling programme of activities and building maintenance and work at height is regularly promoted. HSE will continue to look for opportunities to help farmers manage and control the risks on their premises, including those arising from building integrity.” Source location Response from Health and Safety Executive
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 The incident involved an isolated bespoke solution, and correctly installed concrete panels have no indicated history of integrity or stability problems.
Verbatim wording from the response “The circumstances associated with this instance appear to be an isolated bespoke fabricated solution which in the experience of the HSE is not replicated widely within agricultural buildings. Traditionally concrete panels are a fixed solution and not moved or routinely repurposed. The HSE enquiries looked at the wider use of the pre-cast panels on the farm which were found to be installed in accordance with the manufacturer's instructions.” Source location Response from Health and Safety Executive
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations