20 Jan 2023 Michael John Holmes · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 6 Lack of expertise to assess and control cattle trampling risks on small farms View source Unclear requirements for bringing dogs onto public footpaths near cattle View source Unpredictable aggressive cattle reactions to dogs in fields View source Insufficient oversight and management of public rights of way near grazing cattle View source Cattle trampling hazard when walkers with dogs encounter cows with calves View source Failure to separate walkers from cattle on rights of way View source See 3 more concerns
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AI-generated summary
Michael John Holmes · 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
Michael John Holmes died after being knocked down and trampled by cattle while walking dogs with his wife on a public footpath through a field. The report raised concerns about the risks of walkers, particularly those accompanied by dogs, coming into contact with cattle and calves, and about the management and separation of public footpaths from grazing cattle.
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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 expertise to assess and control cattle trampling risks on small farms
Wider context from the report “4.1. The current potential for a hazard to be created by walkers on public footpaths moving in proximity to a farmer’s grazing cattle, requires management of these competing interests. It was contended at the inquest that the farmer is subject to a statutory duty to carry out a risk assessment in accordance with the Management of Health & Safety at Work Regulations 1999. It was contended that a landowner must conduct his business around the existing public footpath, irrespective of which came into existence first. Whilst not disputing the legal duty imposed on a farmer in these circumstances, the potential mischief left unguarded in that analysis, is that Small & Medium Enterprises (SME’s) such as small family farms may lack the expertise to recognise the problem, carry out an effective risk assessment in relation to cattle trampling risks and devise reasonably practicable control measures.
” 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 requirements for bringing dogs onto public footpaths near cattle
Wider context from the report “2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common factors in trampling incidents are cows with calves and walkers with dogs. Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence about four previous incidents in the incident field, three of which involved walkers accompanied by dogs. There appears to be a strong correlation between trampling incidents and walkers with dogs.
2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, particularly when the calves are young.
2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual accompaniment’ and are thus entitled to be brought onto a Right of Way. This proposition lacks clarity. There is also uncertainty as to whether dogs are required to be on a lead when on a public footpath.
” 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 Unpredictable aggressive cattle reactions to dogs in fields
Wider context from the report “3.1. It is difficult to predict whether a particular cow will react aggressively to the presence of a dog in a field. It was suggested during the inquest, the risk of such a reaction is highest in the months after the birth of a calf.
” 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 oversight and management of public rights of way near grazing cattle
Wider context from the report “4.2. To avoid the harm envisaged by further deaths in comparable circumstances, the HSE and Local Authorities should explore ways to apply their expertise in collaboration with landowners (of the type involved in this inquest), whether on a paid or voluntary basis. The maintenance of safe public rights of way could be said to require oversight and management by public bodies as well as the landowners concerned
” 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 Cattle trampling hazard when walkers with dogs encounter cows with calves
Wider context from the report “2.1. HSE Information sheet No 17EW (rev1) published 05/19 states the two most common factors in trampling incidents are cows with calves and walkers with dogs . Mr & Mrs Holmes had two dogs on leads at the time. The inquest heard evidence about four previous incidents in the incident field, three of which involved walkers accompanied by dogs. There appears to be a strong correlation between trampling incidents and walkers with dogs.
2.2. The conclusion to be drawn is that cows with calves and dogs do not mix well, particularly when the calves are young.
2.3. Evidence was given at the inquest to the effect that dogs are regarded as a ‘usual accompaniment’ and are thus entitled to be brought onto a Right of Way. This proposition lacks clarity. There is also uncertainty as to whether dogs are required to be on a lead when on a public footpath.
” 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 separate walkers from cattle on rights of way
Wider context from the report “1.2. Statistics from the Health & Safety Executive (‘HSE’) indicate that on average 6 people have died each year from injuries sustained in cattle trampling incidents. 11 people died in 2020, one of whom was Mr Holmes. Such incidents are avoidable if walkers and cattle are separated. In my judgment, this unacceptable situation necessitates a review of the arrangements in which walkers are brought into contact with cows and their calves, by virtue of rights of way .
” 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 Review AIS17 guidance and consider the report’s comments on including information about applying to reroute public footpaths.
Verbatim wording from the response “Finally, thank you for your suggestion to include additional information in AIS17 on the mechanism to apply for a public footpath to be re-routed. We keep guidance, including AIS17, under periodic re-evaluation. When next reviewed, we will take your comments into consideration.” 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 Posting field notices advising walkers not to bring dogs among animals during specified dates is outside HSE’s regulatory remit.
Verbatim wording from the response “The specific matter of posting notices at the entrance to particular fields specifically to advise walkers not to bring dogs into a field containing animals between certain dates is outside of HSE’s remit as a regulator, and is more appropriate for others to offer comment.” 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 Existing cattle-management controls, if followed, provide reasonable mitigation and limit risk to a low level.
Verbatim wording from the response “Farmers have a duty to manage the risk created by placing cattle in fields with public rights of way. HSE does recognise that the presence of a dog(s) and cows with calves does increase the risk of incidents. However, the control measures already outlined, if followed, limit the times when cattle with calves are in fields with public access, and if there is no alternative provide reasonable mitigation to control the risk to a low level.” 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 Empowering local-authority footpath officers to prohibit dogs temporarily is outside HSE’s role.
Verbatim wording from the response “HSE has no role in empowering LA footpath officers to prohibit dogs from fields for specified periods so we can’t comment on this aspect of your report.” 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 Defra is responsible for rights-of-way legislation, including footpath diversions and advice on dogs using public rights of way.
Verbatim wording from the response “I understand from your report, that the farmer made a formal application to divert the public footpath to the edge of the incident field and erect suitable fencing to create a safe corridor and segregate walkers from cattle. The legislation regarding rights of way falls under Defra’s responsibility and is not a matter for HSE, although we understand that the divert process can take time and does not offer a prompt solution. The issue of diversions, whether temporary or permanent, and of the provision of permissive alternative routes, is not straightforward, and may not always offer the best solution to manage the risks.” 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 Local-authority officers principally manage and maintain public rights of way, so HSE is not the appropriate authority for related oversight.
Verbatim wording from the response “The maintenance and management of public rights of way is principally governed by local authority officers. HSE is not the appropriate authority to comment on the Highways Act provisions and the oversight matters you mention.” Source location Response from Health and Safety Executive
Open published response
30 Dec 2022 Malcolm James BASTEN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 5 Lack of mandatory accredited health and safety training for principal contractors before project engagement View source Lack of mandatory accredited health and safety training for principal contractors after a project incident View source Lack of mandatory HSE notification of projects undertaken by principal contractors after an incident View source Lack of mandatory statutory agency inspection during construction View source Lack of mandatory notification of construction work to a statutory agency View source See 2 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
Malcolm James BASTEN · 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
Malcolm James Basten died after sustaining head and chest injuries in a fall while working at height on a construction site. The report identified inadequate safeguards, including no edge protection, incomplete boarding, no safe internal access, and an unsecured scaffold ladder. Concerns also included the absence of required notification and inspection for this project and no mandatory accredited health and safety training requirements for principal contractors.
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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 mandatory accredited health and safety training for principal contractors before project engagement
Wider context from the report “2. There is no mandatory requirement for the principal contractor to undertake health and safety training from an accredited organisation before engaging in this type of project .
” 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 mandatory accredited health and safety training for principal contractors after a project incident
Wider context from the report “3. There is no mandatory requirement for principal contractors to undertake health and safety training from an accredited organisation after an incident such as this has occurred on one of their projects , nor to notify the HSE of any projects they undertake thereafter.
” 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 mandatory HSE notification of projects undertaken by principal contractors after an incident
Wider context from the report “3. There is no mandatory requirement for principal contractors to undertake health and safety training from an accredited organisation after an incident such as this has occurred on one of their projects, nor to notify the HSE of any projects they undertake thereafter .
” 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 mandatory statutory agency inspection during construction
Wider context from the report “1. This was a sizable project with considerable work at height. No statutory agency was required to be notified of the work and then inspect the project during the construction .
” 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 mandatory notification of construction work to a statutory agency
Wider context from the report “1. This was a sizable project with considerable work at height. No statutory agency was required to be notified of the work and then inspect the project during the construction.
” 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 CDM skills, knowledge and experience requirements, supported by guidance, are considered sufficient without mandatory accredited principal-contractor training.
Verbatim wording from the response “Although there is no mandatory requirement for the duty holder to undertake health and safety training Regulation 8 of CDM requires that anyone undertaking construction work must be able to demonstrate that they have the appropriate health and safety skills, knowledge, experience. Where they are an organisation, the organisation should have the capability to carry out the work in a way that secures health and safety. If the dutyholder cannot demonstrate that they have these attributes then they should not accept the work.” 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 Current notification thresholds identify significant projects and help target finite regulatory resources; expanding them would add burdens without significant benefit.
Verbatim wording from the response “For the year 2021/22 there were 51,530 new notifications of construction projects in Great Britain. This figure doesn’t include ongoing projects previously notified. Many more construction sites don’t meet the threshold for notification and go ahead without any formal notification, such as the site Mr Basten was working on.” 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 Existing enforcement arrangements address post-incident capability concerns; previous performance informs future enforcement without mandatory training or project notification.
Verbatim wording from the response “HSE’s Enforcement Policy Statement (EPS) sets out the principles inspectors should apply when determining what enforcement action to take in response to breaches of health and safety legislation. Fundamental to this is the principle that enforcement action should be proportional to the health and safety risks and the seriousness of the breach. This means that if a lack of health and safety capability played a part in an incident, then requiring a dutyholder to undertake training will be a potential line of enforcement for HSE.” Source location Response from Health and Safety Executive
Open published response
4 Nov 2022 Levi Louis Alleyne · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of Standard Operating Procedure instructions to contact the local DNO during electrical hazards View source Fragmented DNO emergency contact arrangements across ambulance service boundaries View source Delays to life-saving treatment due to uncertainty about whether OHPLs remain live View source Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators View source Risk to bystanders and emergency services from approaching patients near live OHPLs View source See 2 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
Levi Louis Alleyne · 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
Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.
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× 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 Standard Operating Procedure instructions to contact the local DNO during electrical hazards
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off . There is no such instruction in the national Standard Operating Procedure .
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Fragmented DNO emergency contact arrangements across ambulance service boundaries
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact . There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries . Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand . The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO .
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 to life-saving treatment due to uncertainty about whether OHPLs remain live
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live . There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live ,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 Unavailability and poor accessibility of correct DNO emergency numbers to ambulance control centre operators
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes . The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known .
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” 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 to bystanders and emergency services from approaching patients near live OHPLs
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact. There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries. Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand. The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO.
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live .
” 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 Share concerns with police and fire health and safety bodies to promote suitable emergency procedures for electricity-network incidents.
Verbatim wording from the response “HSE has also shared these concerns with the Association of Police Health and Safety Advisors (APHSAs), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and Safety Committee to ensure all emergency services are aware and check they have suitable procedures in place to deal with incidents involving equipment on the electricity network.” 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 Share the report with CQC and HIW for consideration within their respective healthcare safety remits.
Verbatim wording from the response “In relation to the first concern, 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.” 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 Comment on the draft Safety Advice for the Emergency Services information leaflet during its review.
Verbatim wording from the response “The ENA are currently reviewing their information leaflet on Safety Advice for the Emergency Services. HSE has commented on the draft document and the review is due to be completed by the end of January 2023.” 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 Care Quality Commission is responsible for considering delays to life-saving ambulance treatment in England.
Verbatim wording from the response “This means that delays to life-saving treatment for patients provided by the ambulance service in England would fall within the remit of CQC and not HSE. We have therefore shared this report with CQC to consider.” 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 Delays to life-saving ambulance treatment in England fall outside the respondent’s remit and within the Care Quality Commission’s remit.
Verbatim wording from the response “In relation to the first concern, 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.” 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 Distribution and transmission network operators have suitable and effective arrangements with local emergency services for incidents involving electricity-network equipment.
Verbatim wording from the response “We have contacted the Energy Networks Association (ENA), who have advised that DNOs and Transmission Network Operators (TNO) have suitable and effective arrangements in place with their local emergency services providers. This includes ensuring that emergency services have suitable emergency contact details for their DNO and that they know how to respond to an incident involving equipment on the electricity network. In future, the ENA has requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis.” 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 Delays to life-saving treatment in Wales fall outside the respondent’s remit and within Healthcare Inspectorate Wales’s remit.
Verbatim wording from the response “In Wales, the Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of healthcare. HIW’s core role is to review and inspect NHS and independent healthcare organisations in Wales to check that patients, the public, and others are receiving safe and effective care which meets recognised standards. The Memorandum of Understanding between HIW and HSE sets out our roles and responsibilities in further detail. As this would fall within HIW’s remit, we have shared this report with them.” 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 Healthcare Inspectorate Wales is responsible for considering delays to life-saving treatment in Wales.
Verbatim wording from the response “In Wales, the Healthcare Inspectorate Wales (HIW) is the independent inspectorate and regulator of healthcare. HIW’s core role is to review and inspect NHS and independent healthcare organisations in Wales to check that patients, the public, and others are receiving safe and effective care which meets recognised standards. The Memorandum of Understanding between HIW and HSE sets out our roles and responsibilities in further detail. As this would fall within HIW’s remit, we have shared this report with them.” Source location Response from Health and Safety Executive
Open published response
25 Aug 2022 Charles Evans · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 11 Lack of an emergency response procedure View source Lack of staff training in CPR View source Failure to establish and implement a service-provider action plan for improving quality and safety View source Lack of a proper procedure for staff to report concerns about residents View source Lack of reliable emergency communication facilities in the residents’ dining room View source Failure to ensure staff know who else is on duty View source Failure to conduct further risk assessments after a resident’s return from hospital View source Unavailability of a defibrillator on site View source Unavailability of a registered first aider on the premises View source Lack of staff presence in the communal dining room during mealtimes View source Failure to monitor progress towards the quality and safety action plan View source See 8 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.
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AI-generated summary
Charles Evans · 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
Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.
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× 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 an emergency response procedure
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 staff training in CPR
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR . The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 establish and implement a service-provider action plan for improving quality and safety
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 proper procedure for staff to report concerns about residents
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents ;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 reliable emergency communication facilities in the residents’ dining room
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room . Staff were expected to use their mobile phone to call for help ;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 staff know who else is on duty
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time ;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 further risk assessments after a resident’s return from hospital
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 Unavailability of a defibrillator on site
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site ;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 Unavailability of a registered first aider on the premises
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises ;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 staff presence in the communal dining room during mealtimes
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” 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 monitor progress towards the quality and safety action plan
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan .
” Open source report
Concerns raised 3 Single crewing of the bin collection vehicle View source Failure of the supervision advice document to include checks for persons inside bins View source Bin collection during darkness and poor weather in areas vulnerable to vagrants 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
Adam Albert John Forrester · 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
Adam Albert John Forrester was last seen leaving a nightclub in the early hours of 12 September 2017 and was later found dead in a recycling plant shed. His injuries were compatible with compaction in a bin lorry or other vehicle, and concerns were raised about single-crewed waste collection in darkness and poor weather, and guidance that did not require checking bins for people.
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 Single crewing of the bin collection vehicle
Wider context from the report “(1)The bin waggon had collected bins during the hours of darkness in apparently poor weather conditions and from an area vulnerable to vagrants. The vehicle was single crewed.
” 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 the supervision advice document to include checks for persons inside bins
Wider context from the report “(2)The WISH document, Effective Proactive Monitoring in Waste and Recycling Collection Activities document contains a checklist on page 5 of 8 and a section headed Public Safety at points numbered 20-22. This section makes no mention of kicking bins or checking inside for persons. This is dealt with in the WISH Guidance Document –managing Access to Large Waste and Recycling Bins but not in the supervision advice document.
” 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 Bin collection during darkness and poor weather in areas vulnerable to vagrants
Wider context from the report “(1)The bin waggon had collected bins during the hours of darkness in apparently poor weather conditions and from an area vulnerable to vagrants . The vehicle was single crewed.
” 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 Review existing guidance and control measures for risks associated with people sleeping in or around bins.
Verbatim wording from the response “Having reviewed the guidance, we are content that the existing material and control measures are broadly sufficient and proportionate to the risk. However, we recognise the wording of WISH INFO 3 could be clearer – so we have drafted some modified text at line 13 on page 5 of INFO13 and with the addition of line 21 on page 6: “Crew check all large, four wheeled bins” (to distinguish from the smaller two wheeled domestic types).” Source location 2021-0268-Response-from-HSE_Published
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 Draft clearer WISH INFO 3 wording requiring crews to check all large, four-wheeled bins.
Verbatim wording from the response “I refer to your report of 11th August 2021 which has been passed to me for response as head of HSE’s Waste and Recycling sector team. I have also consulted the Waste Industry Safety and Health forum (WISH) steering group who have many years of experience in the industry to clarify some of the issues. We have worked jointly to amend the guidance, ensure that it is fit for purpose and is as clear as it can be as to the risks and potential control measures. To save duplication, HSE has agreed with WISH that this letter should be regarded as a joint, composite response on behalf of both organisations. I trust this is acceptable.” Source location 2021-0268-Response-from-HSE_Published
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 guidance and control measures are broadly sufficient and proportionate to the risk, although wording for checking large bins could be clearer.
Verbatim wording from the response “Having reviewed the guidance, we are content that the existing material and control measures are broadly sufficient and proportionate to the risk. However, we recognise the wording of WISH INFO 3 could be clearer – so we have drafted some modified text at line 13 on page 5 of INFO13 and with the addition of line 21 on page 6: “Crew check all large, four wheeled bins” (to distinguish from the smaller two wheeled domestic types).” Source location 2021-0268-Response-from-HSE_Published
Open published response
25 Mar 2021 Azra Parveen HUSSAIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Failure to provide families with direct remote participation in MDT meetings View source Failure to raise incident reports for significant suicide-related information View source Failure to record significant family concerns and patient accounts View source Failure to update risk screens after significant changes in presentation View source Failure to remove or mitigate ligature risks from bedroom-area doors View source Failure to communicate significant risk information in handovers and MDTs View source Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units View source See 4 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
Azra Parveen HUSSAIN · 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
Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.
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 provide families with direct remote participation in MDT meetings
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 raise incident reports for significant suicide-related information
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised , and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 record significant family concerns and patient accounts
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra . Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 update risk screens after significant changes in presentation
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated , an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 remove or mitigate ligature risks from bedroom-area doors
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk : the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.
” 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 significant risk information in handovers and MDTs
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020 . Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country .
” 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 CQC is responsible for providing the detailed response to concerns about patient environmental safety and ligature risks.
Verbatim wording from the response “This means that both the safety of the environment for the patient, including management of ligature points, and any investigations following incidents would fall within the remit of CQC and not HSE. I am therefore not able to offer any further assistance with respect to the current standards at BSMHT or within England more generally, but I am aware that CQC will be providing a detailed response to your concerns.” Source location 2021-0082-Response-from-Health-and-Safety-Executive-Redacted
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 Patient environmental safety, ligature-point management and incident investigations fall within CQC’s remit, not HSE’s.
Verbatim wording from the response “patients and service users in receipt of a health or adult social care service from a provider registered with CQC. In 2015 (revised in 2017) The Memorandum of Understanding (MoU) between the Care Quality Commission (CQC) and the Health and Safety Executive (HSE) established the respective roles and responsibilities of each organisation with regard to health and safety incidents.” Source location 2021-0082-Response-from-Health-and-Safety-Executive-Redacted
Open published response
8 Mar 2021 Adam Joseph Brunskill · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Failure to ensure new employees have the required roofing experience, qualification and health and safety training View source Lack of designated on-site supervision and practical on-the-job training oversight View source Lack of a clear designated structured training programme for new and unqualified employees View source Lack of clearly identifiable supervisory arrangements for new and unqualified employees View source Lack of an employee appraisal system View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adam Joseph Brunskill · 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
Adam Joseph Brunskill fell approximately 8 metres through a fragile glass rooflight while working on a warehouse roof and died the following day from a devastating brain injury. Concerns included his lack of prior roofing experience, accredited training and supervision, together with inadequate safety barriers, designated walkways, safety netting, structured training, supervisory arrangements and appraisal systems.
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 ensure new employees have the required roofing experience, qualification and health and safety training
Wider context from the report “(1) The Coroner heard at inquest that Adam had been employed by Wayne Clarey Roofing and Cladding to work on a roof with no prior experience of working on a roof and no CSCS card nor had he completed a mandatory one-day Health & Safety 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 Lack of designated on-site supervision and practical on-the-job training oversight
Wider context from the report “(2) On day 13/7/20 and 14/7/20 there was no evidence of a designated supervisor responsible for Adam on site and/or responsible for Adam’s practical on the job 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 a clear designated structured training programme for new and unqualified employees
Wider context from the report “(3) The Coroner did hear in evidence that one of the Principal Contractors who provided regular work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified employees of Wayne Clarey and provide access to an accredited training qualification and training matrix. The Coroner also heard that Mr Clarey had legal responsibilities under the Health & Safety at Work Act and the Construction (Design and Management) Regulations 2015. However, there was no evidence of any clear designated structured training programme in place by Wayne Clarey Roofing and Cladding for new and/or unqualified employees ;
” 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 clearly identifiable supervisory arrangements for new and unqualified employees
Wider context from the report “(4) The Coroner did hear in evidence that one of the Principal Contractors who provided regular work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified employees of Wayne Clarey and provide access to an accredited training qualification and training matrix. The Coroner also heard that Mr Clarey had legal responsibilities under the Health & Safety at Work Act and the Construction (Design and Management) Regulations 2015. However, there was no evidence of any clearly identifiable supervisor and/or supervisory arrangements in place by Wayne Clarey Roofing and Cladding for new and/or unqualified employees ;
” 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 an employee appraisal system
Wider context from the report “(5) The Coroner did hear in evidence that one of the Principal Contractors who provided regular work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified employees of Wayne Clarey and provide access to an accredited training qualification and training matrix. The Coroner also heard that Mr Clarey had legal responsibilities under the Health & Safety at Work Act and the Construction (Design and Management) Regulations 2015. However, there was no evidence of any appraisal system in place by Wayne Clarey Roofing and Cladding .
” 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 Existing supervisory training and deputising arrangements were considered appropriate for the subcontractor’s team.
Verbatim wording from the response “████████ and one of his workers had SSSTS, which is an appropriate level of supervisory training for them, for a team of four, including deputising cover if ████████ was not on site.” Source location 2021-0384-Response-from-Health-Safety-Executive_Published
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 Lack of a designated supervisor was not considered to have caused the death because physical fall prevention should have prevented it.
Verbatim wording from the response “Similarly, whilst we do not believe that lack of a designated supervisor led to Adam’s death, as it should have been prevented by physically stopping a fall from the roof to the floor below, we agree with the Coroner in this matter as well that future deaths may be prevented by improvements in supervision.” Source location 2021-0384-Response-from-Health-Safety-Executive_Published
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 Principal Contractor’s training-matrix system, including appraisals and training-needs analysis, was considered sufficient for subcontractors.
Verbatim wording from the response “In their revised Contract For Services document, Proclad state that their training matrix system will be available to subcontractors. As Wayne Clarey Roofing & Cladding Ltd continue to work full time for Proclad, and they fully use their systems, this will include appraisals and training needs analysis.” Source location 2021-0384-Response-from-Health-Safety-Executive_Published
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 Lack of training was not considered the main cause of the accident; failure to prevent the fall was the material safety issue.
Verbatim wording from the response “It is important to make clear HSE’s view that regardless of his experience or inexperience, Adam Brunskill’s death should have been prevented, not by training, but by the risk assessor recognising the fragile nature of the rooflights during their risk assessment, and by the consequent management of that risk. This could have been by means of avoiding the risk with collective means or personal means, by barriers or coverings, and by netting below to minimise the consequences of a fall through the fragile surfaces. The fall from roof to floor should not have been possible.” Source location 2021-0384-Response-from-Health-Safety-Executive_Published
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 Principal Contractor training support and training-matrix arrangements, extended to subcontractors, were considered sufficient for identified training needs.
Verbatim wording from the response “In their revised Contract For Services document, Proclad state that they are happy to provide support to subcontractors in facilitating training for workers, and to grant access to their training matrix systems. Wayne Clarey Roofing & Cladding Ltd will use this arrangement.” Source location 2021-0384-Response-from-Health-Safety-Executive_Published
Open published response
18 Jan 2021 Mrs Lynn Hadley · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Lack of user knowledge of oxygen-cylinder ignition mechanisms and their ramifications View source Risk of ignition within oxygen-cylinder valve components View source Failure to follow the safe valve-opening sequence for oxygen regulators View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Lynn Hadley · 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 13 April 2020, paramedics attended Mrs Lynn Hadley at home for COVID-19-type symptoms and began administering oxygen. The oxygen cylinder sparked and caught fire, and despite efforts by family members and paramedics, Mrs Hadley could not be removed from the house and died from fatal burn injuries. The concerns included possible ignition caused by adiabatic compression or particle impact when the oxygen regulator was opened, limited awareness of these risks among equipment users, and other reported cases of ignition involving oxygen-cylinder valve components.
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 user knowledge of oxygen-cylinder ignition mechanisms and their ramifications
Wider context from the report “4. Evidence from the Fire Investigation Officer, confirmed that there was little if any knowledge of either adiabatic compression or particle impact and the ramifications of such an event when opening a cylinder incorrectly by those responsible for using the equipment .
” 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 ignition within oxygen-cylinder valve components
Wider context from the report “5. Evidence from the MHRA confirmed that they are aware of four cases of ignition within valve components of oxygen cylinders leading to fire since 2011 including this incident . The valve manufacturer VTI, Germany has subsequently reported nine cases of ignition . VTI are also examining a further 20 regulators. At present no defects have been found.
” 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 follow the safe valve-opening sequence for oxygen regulators
Wider context from the report “2. Although both of these phenomena are extremely rare, the sudden uncontrolled release of oxygen by rapidly opening the on/off valve of the regulator can expedite the occurrence of ignition .
3. Evidence from the paramedic confirmed that she opened the patient valve first before opening the on/off valve, thus increasing the chance of the reported phenomena occurring .
” 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 Use HSE communication channels and stakeholder networks to disseminate MHRA information or guidance on safe oxygen-cylinder use.
Verbatim wording from the response “Once completed, we will:” Source location 2021-0346-Response-from-Health-and-Safety-Executive_Published
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 Consider whether HSE should take further action, including updating oxygen-cylinder safety guidance to reflect new MHRA information or guidance.
Verbatim wording from the response “Once completed, we will:” Source location 2021-0346-Response-from-Health-and-Safety-Executive_Published
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 It is premature for HSE to consider action before MHRA’s investigative and regulatory work is completed.
Verbatim wording from the response “HSE continues to support MHRA and we believe it would be premature for us to consider taking any action before their work is completed.” Source location 2021-0346-Response-from-Health-and-Safety-Executive_Published
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 MHRA is the lead authority and regulator for the equipment involved, so it leads the relevant investigation and regulatory action.
Verbatim wording from the response “MHRA are the lead authority, as they are the regulator for the equipment involved in this incident. However, during the investigation a Multidisciplinary Team (MDT), comprising the Care Quality Commission, West Midlands Ambulance Service, West Midlands Fire Service, MHRA, Medical Gas Solutions and HSE, was established to:” Source location 2021-0346-Response-from-Health-and-Safety-Executive_Published
Open published response
17 Apr 2020 Ashley Mark Holden · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 3 Inconsistent and uncoordinated guidance on bale safety View source Lack of definitive guidance on loading and strapping loaded trailers for differing bale and trailer configurations View source Lack of definitive guidance on stacking or unstacking bales View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ashley Mark Holden · 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 10 November 2018, HGV driver Ashley Holden was struck by a falling straw bale while collecting bales from a farm and sustained a fatal head injury. The report identified inconsistent guidance and a lack of definitive guidance on stacking, unstacking, loading and strapping bales, creating a risk of unsafe practices and future deaths.
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 Inconsistent and uncoordinated guidance on bale safety
Wider context from the report “3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance .
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential 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 Lack of definitive guidance on loading and strapping loaded trailers for differing bale and trailer configurations
Wider context from the report “3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance.
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential 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 Lack of definitive guidance on stacking or unstacking bales
Wider context from the report “3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance.
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales , or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future 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 Review INDG125, taking account of submitted comments and considering whether improvements can be made.
Verbatim wording from the response “incidents and modern farming practices. For example, INDG125(rev3) was revised in 2012 to provide updated guidance to the industry on safe working practices, including the safe loading and unloading of bales. The DfT guidance Code of Practice: Safety of loads on vehicles is already referenced in INDG125 under the ‘Find out More’ section of the leaflet on page 10. We are grateful for your comments and we will take them into account at the next review.” Source location 2020-0096-Response-from-Health-Safety-England_Redacted-1
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 Provide vehicle-loading training and specialist technical support to frontline personnel, alongside load-securing advice through agricultural forums.
Verbatim wording from the response “HSE recognise that unstable loads present a serious risk of harm during loading and unloading. In 2013 we worked with DVSA to introduce a new enforcement approach for vehicle loading, and produced updated on-road guidance on load securing for vehicle operators, which was published in 2015. We continue to work closely with DVSA and police forces, providing training on vehicle loading for frontline personnel alongside specialist technical support. We also provide loading and load securing advice through wider forums to the agricultural sector.” Source location 2020-0096-Response-from-Health-Safety-England_Redacted-1
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 Monitor incidents and modern farming practices and adapt bale-loading guidance accordingly.
Verbatim wording from the response “The risk of fatal and serious injury when working with bales in agriculture is well known and guidance has been in place in various forms for decades. Recently, between 2014 and 2019, 6 people were killed by falling bales. We continue to monitor and adapt our guidance in light of” Source location 2020-0096-Response-from-Health-Safety-England_Redacted-1
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 Produce and publish updated on-road load-securing guidance for vehicle operators.
Verbatim wording from the response “HSE recognise that unstable loads present a serious risk of harm during loading and unloading. In 2013 we worked with DVSA to introduce a new enforcement approach for vehicle loading, and produced updated on-road guidance on load securing for vehicle operators, which was published in 2015. We continue to work closely with DVSA and police forces, providing training on vehicle loading for frontline personnel alongside specialist technical support. We also provide loading and load securing advice through wider forums to the agricultural sector.” Source location 2020-0096-Response-from-Health-Safety-England_Redacted-1
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 broad guidance and the legal framework are considered sufficient because risk assessment, planning and competent staff can safely manage varied bale-loading configurations.
Verbatim wording from the response “The guidance contained in INDG125 is intentionally broad and sets out the principles of safe loading that meet the Act and LOLER. It has never been our intention to cover every possible configuration but the combination of suitable and sufficient assessment, planning and use of competent people allows for loads of many types to be loaded and transported safely within a robust legal framework.” Source location 2020-0096-Response-from-Health-Safety-England_Redacted-1
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 Employers and those controlling loading operations are responsible for identifying risks, implementing effective controls and reviewing them.
Verbatim wording from the response “The duty rests on employers and those in control of the loading operations to identify risks associated with the loading operation, implement effective controls to ensure the safety of persons who may be affected, and keep these controls under review.” Source location 2020-0096-Response-from-Health-Safety-England_Redacted-1
Open published response
17 Dec 2019 Eugeniusz Malek · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Uncapped ends of scaffolding poles in areas where workers may fall, trip or collide with them 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.
×
AI-generated summary
Eugeniusz Malek · 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
Eugeniusz Malek, a 50-year-old plasterer, fell from a ladder onto an uncapped scaffolding pole on 23 June 2018 and sustained fatal injuries. The principal concern was that ends of scaffolding poles in areas where workers may fall, trip or collide with them should be capped.
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 Uncapped ends of scaffolding poles in areas where workers may fall, trip or collide with them
Wider context from the report “1. That ends of scaffolding poles sited in areas where workers may fall, trip or collide with them should be capped .
” Open source report
23 Sep 2019 Kristiyan Petrov Danailov · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of industry awareness of risks when dealing with customers over the internet View source Insufficient safeguards against vulnerable individuals purchasing hazardous items View source Insufficient identity checks before postal dispatch of hazardous items 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.
×
AI-generated summary
Kristiyan Petrov Danailov · 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
Kristiyan Petrov Danailov was found unresponsive at home on 28 July 2018 after purchasing an online product labelled as containing cyanide, and was pronounced deceased at the scene. The inquest concluded that the death was suicide, with the medical cause recorded as consistent with cyanide poisoning. Concerns were raised about checks on the identity and vulnerability of customers purchasing hazardous items online and about industry awareness of the risks.
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 industry awareness of risks when dealing with customers over the internet
Wider context from the report “I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post. What obstacles are in place to prevent vulnerable individuals purchasing such items ?
II. Are members of the industry aware of the potential risks when dealing with customers over the internet .
” 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 safeguards against vulnerable individuals purchasing hazardous items
Wider context from the report “I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post. What obstacles are in place to prevent vulnerable individuals purchasing such items ?
II. Are members of the industry aware of the potential risks when dealing with customers over the internet.
” 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 identity checks before postal dispatch of hazardous items
Wider context from the report “I. There appears to be insufficient checks carried out as to the identity of the prospective customer before hazardous items are sent out in the post . What obstacles are in place to prevent vulnerable individuals purchasing such items ?
II. Are members of the industry aware of the potential risks when dealing with customers over the internet.
” Open source report
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Failure of mental health trusts to communicate placement information with private providers and families View source Failure to consider discharge medication and prescribing risk View source Failure of discharge planning to share risk information with GPs and families View source Failure of private providers to obtain relevant clinical information from referring services View source Failure to provide care coordination after placement with a private provider View source Insufficient mental health training and specialist liaison for university welfare staff View source Failure of universities to identify early signs of anxiety and mental health issues in students View source Lack of alternative mental health provision for young adults View source Lack of suitable acute mental health beds for young adults View source Inadequate guidance on glass balustrade safety where climbable furniture is adjacent View source Failure to communicate the change in risk level when patients leave a secure environment View source See 8 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
Hannah Dolly Kaur Bharaj · 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
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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 mental health trusts to communicate placement information with private providers and families
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement . A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken 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 consider discharge medication and prescribing risk
Wider context from the report “2. There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU . As a result Hannah was prescribed a month’s supply of medication;
” 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 discharge planning to share risk information with GPs and families
Wider context from the report “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective . Key information was not shared with the GP or the family particularly when care moved back to the family ;
” 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 private providers to obtain relevant clinical information from referring services
Wider context from the report “5.The expectations around information sharing with private providers and the expectation on private providers contracted by the NHS to seek information. The Priory did not request any notes from the EDU about Hannah . As a result they were unaware of detailed information held by the Trust regarding previously expressed suicidal ideation ;
” 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 care coordination after placement with a private provider
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken 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 Insufficient mental health training and specialist liaison for university welfare staff
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective ;
” 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 universities to identify early signs of anxiety and mental health issues in students
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing . As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage . The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective;
” 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 alternative mental health provision for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative . The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” 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 suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” 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 guidance on glass balustrade safety where climbable furniture is adjacent
Wider context from the report “8. The guidance in relation to the height of glass balustrades where items such as tables, in cafes open to the public including children and other vulnerable people, are placed in close proximity to the glass. The glass balustrade in John Lewis was at a height that accorded with the required standard but by simply climbing onto the table that was adjacent to the balustrade Hannah was able to easily go over the balustrade.
” 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 the change in risk level when patients leave a secure environment
Wider context from the report “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family;
” Open source report
Concerns raised 10 Inadequate tiger-enclosure entry method statement and risk assessment View source Insufficiently clear and prescriptive guidance on double gates for tiger enclosures View source Over-reliance on individual keeper reliability as the tiger-enclosure entry control View source Lack of clear guidance requiring licensed conventional firearms at zoos holding tigers View source Absence of double keeper gates to tiger paddocks View source Inadequate fatigue-risk controls for keepers undertaking night-time hand-rearing View source Insufficient inspection and guidance attention to human-factors risks in tiger-enclosure entry systems View source Insufficient trained firearms staff to provide continuous zoo cover View source Failure to complete approval, secure storage and acquisition of conventional firearms View source Lack of access to conventional firearms for escaped or uncontrolled tigers View source See 7 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
ROSA ANN KING · 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
Rosa Ann King, a senior carnivore keeper at Hamerton Zoological Park, died on 29 May 2017 after being attacked by a Malayan tiger while exiting the tiger paddock. She had entered while the tiger slides were open, and the report identified concerns about reliance on keeper reliability, fatigue from night-time hand-rearing work, the absence of air-lock type double gates, and lack of access to conventional firearms. The report also raised concerns about insufficient guidance, risk assessment and inspection of these safety arrangements.
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 Inadequate tiger-enclosure entry method statement and risk assessment
Wider context from the report “5.4.2 I heard evidence that Hamerton zoo’s “Review of Tiger Protocols” was not a suitable method statement for working in the tiger enclosures . It did not explicitly set out every necessary stage of checks in the system for entering a tiger area ; it had not been updated; it addressed only some of the tasks that were required (for example, it did not address entry into the Tiger paddock where Rosa was attacked). I heard evidence that the relevant risk assessment was not suitable ; that it did not consider the risk of human failure , and did not address the risk of a member of staff omitting a critical check or action due to an unintentional slip, lapse or mistake, or an intentional violation.
” 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 Insufficiently clear and prescriptive guidance on double gates for tiger enclosures
Wider context from the report “5.2.6 I am concerned that:
• Hamerton Zoo was able to pass previous ZLA inspections without any recommendation being made that a double keeper gate be fitted to its tiger enclosures.
• The DEFRA guidance by inclusion of the words, “In general …” is insufficiently clear and insufficiently prescriptive on the standards that should apply to an enclosure holding animals as deadly as tigers. Similar considerations apply to the HSE guidance.
The fact that other zoos may not have double keeper gates fitted to tiger enclosures, and the lack of more prescriptive guidance , carry a risk of further 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 Over-reliance on individual keeper reliability as the tiger-enclosure entry control
Wider context from the report “5.4.1 The system for entering the tiger enclosures at Hamerton zoo was simple, and involved a number of visual checks by the tiger keeper. However, as found by the jury, I heard evidence that this system was totally dependent on the keepers reliably following their training . There was no further control measure (whether involving engineering design, a flag or sign system, CCTV, the use of radio checks or otherwise) to limit the human error risk. I heard expert evidence that training on its own is not an effective measure to reduce the risks of slips, lapses or violations. I heard evidence that in relation to a task which carries the risk of single or multiple fatalities, human actions should not be relied on to be the control of the hazard unless as a final resort.
” 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 clear guidance requiring licensed conventional firearms at zoos holding tigers
Wider context from the report “5.1.4 I heard evidence that DEFRA’s “Secretary of State’s Standards of Modern Zoo Practice” is being redrafted/has been redrafted but is not yet published. Paragraph 8.20 of the guidance as currently drafted states,
“Where a zoo holds any primate, carnivore, elephant, or hoofed mammal listed in category 1 of Appendix 12, appropriate firearms must be available, unless a risk assessment has shown that a firearm would not provide the most appropriate means of protection to the public from that animal, and other arrangements have been made.”
I am concerned that the wording of this provision may have contributed to the zoo being able to pass ZLA inspections since it held one form of firearm (a dart gun) and had an arrangement with local police for conventional firearms cover. In contrast, I received evidence from an independent expert and highly experienced zoo manager, designer and consultant that he was “stunned to learn that no firearms were kept on site at Hamerton and they had had tigers since around 2003”. I am concerned that a lack of clear guidance that all zoos which hold tigers must possess licensed conventional firearms carries a risk of further 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 Absence of double keeper gates to tiger paddocks
Wider context from the report “5.2.1 I am concerned that, some time, error on the part of a safety-conscious experienced zoo keeper led to a situation whereby a tiger could have attacked multiple members of the visiting public. Double keeper gates to the tiger paddock would very likely have prevented this risk. They were not fitted at the time.
” 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 fatigue-risk controls for keepers undertaking night-time hand-rearing
Wider context from the report “5.3.2 I heard evidence that since Rosa’s death, the zoo has introduced a formal policy for the hand-rearing of animals. That policy (which on its face was meant to have been reviewed on 24 April 2019) reduces, but does not eliminate, my concerns in this regard. It provides that the period of consecutive days staff spent hand-rearing should be “kept to a minimum”. However, it goes on to provide that this is to be, “at the staff members own discretion” after what is said to be “self-evaluation” . For hand-rearing done at home, the work remains viewed as voluntary and unpaid. The policy does not make provision for the hours spent in such activity to be monitored for safety reasons , although in a document provided on the last day of the inquest, I was told that this would be introduced before any further hand-rearing was done. The policy does not make any separate provision or safeguards for those keepers whose day jobs involve them working with the highest risk animals like tigers , where there is a risk of fatalities if fatigue-induced mistakes are made. No advice had been taken from any outside expert on the safety implications of night-working or the patterns of work being undertaken . I am concerned that there remains a risk of further 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 Insufficient inspection and guidance attention to human-factors risks in tiger-enclosure entry systems
Wider context from the report “5.4.6 In light of the aforesaid, I am concerned that there is an ongoing risk nationally that systems for entering tiger enclosures may be entirely dependent or overly-dependent on the reliability of individual zoo keepers without sufficient account being taken of the risk of human failures . Further, such risks may not be effectively addressed by zoo inspections nor sufficiently publicised in DEFRA and HSE guidance . This carries a risk of further 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 Insufficient trained firearms staff to provide continuous zoo cover
Wider context from the report “5.1.3. Moreover, at present only two members of the zoo staff have been trained to use conventional firearms . I am concerned that this is too few a number to ensure that a member of staff trained in conventional firearms will always be on duty when the public have admittance to the zoo . This carries a risk of further 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 complete approval, secure storage and acquisition of conventional firearms
Wider context from the report “5.1.2 I heard evidence that the zoo has taken measures for two members of staff to obtain firearms’ licences and they have received firearms training. However, I heard evidence that the zoo has not yet been approved as premises to hold firearms (action for which rests with the firearms licensing department at the local constabulary) and the zoo has not yet fitted appropriate firearm secure containers . While moving to hold conventional firearms has been made a condition of the zoo’s licence under the Zoo Licensing Act 1981 (ZLA), I am concerned that more than two years after Rosa’s death, the process of the zoo obtaining conventional firearms has still not been completed . This carries a risk of further 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 access to conventional firearms for escaped or uncontrolled tigers
Wider context from the report “5.1.1. Should a tiger escape from the tiger enclosures at Hamerton Zoo or a keeper should inadvertently find themselves in the same area as a tiger, I am concerned that the zoo still does not currently have access to conventional firearms to shoot a tiger in that situation to preserve human life .
” Open source report
29 Apr 2019 Faye Allen · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Ambiguity in staffing-level guidance for medical-area resources at events 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.
×
AI-generated summary
Faye Allen · 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
Faye Allen became unwell after consuming MDMA at an event on 1 May 2016, went into respiratory arrest while being transported to hospital, and died at Manchester Royal Infirmary on 2 May 2016. The inquest considered concerns that guidance on event medical staffing could be interpreted differently, resulting in substantially varying levels of staff available in medical areas.
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 Ambiguity in staffing-level guidance for medical-area resources at events
Wider context from the report “During the course of the inquest the issue of the availability of paramedics and other medical assistance was considered. The inquest was referred to the National Ambulance Service Guidance for preparing an Emergency Plan specifically Annex B which feeds into the Purple Guide. The annex and its tables set out staffing levels that are recommended for different event types. However, it became clear during the evidence that the recommended levels of staffing could be interpreted in different ways and that for example first aiders deployed in areas other than the medical cabin area were being counted as part of the resource . This meant that staff directly deployed to deal with medical issues in the medical area could vary widely and be significantly below the numbers set out in the tables .
” Open source report
22 Mar 2019 Bram Luke Radcliffe · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 3 Failure to ensure safe installation of fireplace surrounds View source Lack of a British Standard for fixing stone fireplace surrounds View source Exclusion of fire surround provision from Building Regulations 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.
×
AI-generated summary
Bram Luke Radcliffe · 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 8 November 2017, two-year-old Bram Luke Radcliffe was found unresponsive after a marble fireplace surround detached from the wall and struck him. He was taken to hospital but died later that morning from his head injury. Evidence at the inquest indicated that the fireplace surround installation was substandard and dangerous, and raised concerns about the absence of a British Standard for fixing stone fireplace surrounds and their exclusion from building regulations.
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 ensure safe installation of fireplace surrounds
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous , and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” 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 British Standard for fixing stone fireplace surrounds
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture . I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” 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 Exclusion of fire surround provision from Building Regulations
Wider context from the report “During the inquest I heard evidence to indicate that the installation of the fireplace surround was both substandard and dangerous, and that there is currently no British Standard for the fixing of stone fireplace surrounds only for the manufacture. I was informed that the provision of a fire surround is not ‘building work’ as defined by Regulation 3(1) of the Building Regulations 2010 (as amended), therefore would not be the subject to Building Regulations and subject to guidance provided by the manufacturer/supplier and good building practice.
” Open source report
19 Mar 2019 Mark Keith PARRY · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of published guidance for mechanics and their employers on working with air suspensions on heavy goods vehicles View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Keith PARRY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Keith Parry died on 2 March 2017 after being struck on the head by an ejected air-suspension component while repairing a heavy goods vehicle. The report raised concern that there were no published Health and Safety Executive guidelines for mechanics and their employers on working with air suspensions on heavy goods vehicles.
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 published guidance for mechanics and their employers on working with air suspensions on heavy goods vehicles
Wider context from the report “That there are no published guidelines by the Health and Safety Executive to mechanics and those companies that employ mechanics on how to work with or approach working with Air Suspensions on Heavy Goods Vehicles. The value of such guidance is that it would signpost strategies and risks attached to such work.
” 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 Review whether PM85 should be renamed to cover all large vehicles with air-suspension systems.
Verbatim wording from the response “Longer term, I will amend PM85 to address control measures in relation to ejection; and will review whether this guidance can be renamed to relate to all large vehicles with air suspension systems. I hope to complete this by the end of March 2020. HSG261 is also being updated and revised and the content relating to air suspension systems will be reviewed, though as a longer term project.” Source location 2019-0094-Response-by-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 Issue a safety alert identifying control measures and air-suspension risks across all vehicle types, then publish and publicise it through industry channels.
Verbatim wording from the response “HSE therefore plan to issue a safety alert, identifying the required control measures and emphasising the risks are present on all vehicle types with air suspension systems. As you can appreciate, this will take some time, as it will require consultation with industry; I hope this will be finalised by August 2019. The safety alert will be published on the HSE website and publicised through trade associations and e-bulletins.” Source location 2019-0094-Response-by-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 Amend PM85 to address control measures for ejection hazards from air-suspension systems.
Verbatim wording from the response “Longer term, I will amend PM85 to address control measures in relation to ejection; and will review whether this guidance can be renamed to relate to all large vehicles with air suspension systems. I hope to complete this by the end of March 2020. HSG261 is also being updated and revised and the content relating to air suspension systems will be reviewed, though as a longer term project.” Source location 2019-0094-Response-by-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 Update and revise HSG261, including reviewing its content on air-suspension systems.
Verbatim wording from the response “Longer term, I will amend PM85 to address control measures in relation to ejection; and will review whether this guidance can be renamed to relate to all large vehicles with air suspension systems. I hope to complete this by the end of March 2020. HSG261 is also being updated and revised and the content relating to air suspension systems will be reviewed, though as a longer term project.” Source location 2019-0094-Response-by-HSE
Open published response
Concerns raised 2 Reliance on divers’ self-reporting failing to ensure disclosure of salient health facts View source Lack of requirement to obtain divers’ General Practitioner records or enquire into other practitioners’ treatment or advice 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.
×
AI-generated summary
Kevin Robert Miles · 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 Robert Miles was undertaking a re-breather diving course at Stoney Cove on 25 September 2018 when he experienced difficulties underwater. He was brought to the surface, but resuscitation attempts failed and he was declared deceased at the scene; the cause of death was recorded as unascertained. The report raised concerns about the absence of a requirement to obtain divers’ GP records or otherwise verify medical advice when assessing fitness to dive, and about the risks to divers and potential rescuers or dive buddies.
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 Reliance on divers’ self-reporting failing to ensure disclosure of salient health facts
Wider context from the report “An Occupational Health Physician, who is also a UK Sport Diving Medical Referee and an HSE Approved Medical Examiner of Divers certified Mr Miles as fit to dive for two years on the 30 January 2018 based on the information given to her by Mr Miles himself in the medical questionnaire and on her physical examination of him. There is currently no requirement to obtain the diver’s General Practitioner records (which are often a ‘hub’ of various information regarding treatment by both hospital and/or private clinic) or otherwise personally enquire into treatment or advice given by any other medical practitioner. In my opinion this system is open for misreporting of health problems or, in fact, failing to report them at all . If there had been a requirement to obtain Mr Miles GP records it would have been quite clear that he had been advised that he should not dive again and presumably the certificate would not have been granted.
My concerns are that not only may divers be risking their own lives by not disclosing salient health facts (that is at their own risk) but that they are also putting the lives of potential rescuers/dive buddies at risk as well.
” 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 requirement to obtain divers’ General Practitioner records or enquire into other practitioners’ treatment or advice
Wider context from the report “An Occupational Health Physician, who is also a UK Sport Diving Medical Referee and an HSE Approved Medical Examiner of Divers certified Mr Miles as fit to dive for two years on the 30 January 2018 based on the information given to her by Mr Miles himself in the medical questionnaire and on her physical examination of him. There is currently no requirement to obtain the diver’s General Practitioner records (which are often a ‘hub’ of various information regarding treatment by both hospital and/or private clinic) or otherwise personally enquire into treatment or advice given by any other medical practitioner . In my opinion this system is open for misreporting of health problems or, in fact, failing to report them at all. If there had been a requirement to obtain Mr Miles GP records it would have been quite clear that he had been advised that he should not dive again and presumably the certificate would not have been granted.
My concerns are that not only may divers be risking their own lives by not disclosing salient health facts (that is at their own risk) but that they are also putting the lives of potential rescuers/dive buddies at risk as well.
” Open source report
15 Feb 2019 Dwayne Daniel Ryan Thompson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to maintain effective physical access controls at reservoirs View source Failure to design reservoir risk signage for people with learning disabilities 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.
×
AI-generated summary
Dwayne Daniel Ryan Thompson · 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
Dwayne Daniel Ryan Thompson went swimming at the Reservoir at Audenshaw on 28 June 2018, got into difficulties, went underwater, and later died in hospital after suffering a catastrophic brain injury. The inquest heard that the reservoir’s fence was regularly damaged and that its warning signs, although compliant with HSE guidance, had not been shown to take account of the needs and understanding of people with learning disabilities.
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 maintain effective physical access controls at reservoirs
Wider context from the report “The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim in/cool down in during the heat of the summer. It was unusual in having a fence and the majority of reservoirs were easily accessible by the public . There was signage to warn of the risks of swimming in reservoirs. This signage was used across all reservoirs including those with open access to them. It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when they were devised.
” 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 design reservoir risk signage for people with learning disabilities
Wider context from the report “The inquest heard that Dwayne Thompson had significant learning disabilities. This reservoir had a fence to prevent access but this was regularly damaged and access was gained with relative ease by locals who used the reservoir to swim in/cool down in during the heat of the summer. It was unusual in having a fence and the majority of reservoirs were easily accessible by the public. There was signage to warn of the risks of swimming in reservoirs. This signage was used across all reservoirs including those with open access to them. It was the main way in which the utility company made the public aware of the risks of the reservoirs. The signage complied with the HSE guidance but the inquest heard that the signs had been in existence for many years and there was no evidence that the needs and understanding of those with learning disabilities had been considered when they were devised .
” Open source report
27 Dec 2018 Kenneth Roy Bardsley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of statutory minimum requirements for lift servicing View source Lack of a care home system for reviewing and passing lift examination details to the servicing company View source Lack of formal minimum qualification standards for lift engineers View source Lack of clarity about informing engineers of and following up regulatory lift examination requirements View source Electronic lift servicing appointment systems lacking checklists View source Failure of home inspections to identify unacted-on regulatory lift examination faults View source Failure to read, act on, and escalate regulatory lift examination findings View source Failure to require lift servicing and repair engineers to obtain regulatory examination reports View source See 5 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
Kenneth Roy Bardsley · 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
Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.
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 statutory minimum requirements for lift servicing
Wider context from the report “7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist. One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service .
” 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 care home system for reviewing and passing lift examination details to the servicing company
Wider context from the report “5. That Serendipity Care Home did not have a system in place to ensure details from the lift examinations were read; considered and passed on to the lift servicing company ;
” 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 formal minimum qualification standards for lift engineers
Wider context from the report “1. The inquest heard that there are no formal requirements for a minimum standard of qualification for people to be lift engineers . In effect, anyone can advertise themselves as a lift engineer/maintenance company ;
” 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 informing engineers of and following up regulatory lift examination requirements
Wider context from the report “3. During the inquest evidence was given that within the specific lift company in this case and more widely, there was a lack of clarity as to how engineers should be made aware and follow up requirements made by engineers carrying out the regulatory lift examinations ;
” 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 Electronic lift servicing appointment systems lacking checklists
Wider context from the report “7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist . One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service.
” 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 home inspections to identify unacted-on regulatory lift examination faults
Wider context from the report “4. In inspections of the home, the CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon ;
” 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 read, act on, and escalate regulatory lift examination findings
Wider context from the report “2. The evidence given to the inquest was that there was a gap in the system which meant that regulatory lift examinations could take place but not be read or acted upon , with no escalation process ;
” 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 lift servicing and repair engineers to obtain regulatory examination reports
Wider context from the report “6. That the lift company Lancs and Cumbria engineers carrying out serving/repairs were not expected to ask to see the regulatory examination reports ;
” Open source report
Concerns raised 5 Failure to control high-volume music use while operating heavy machinery View source Lack of policy governing music and CD use while operating machinery View source Failure to review or update the drugs policy View source Failure to eliminate simultaneous pedestrian and vehicle movement on the factory floor View source Lack of random drug testing for drivers operating heavy machinery View source See 2 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
Austin Allen Ellsum THOMAS · 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
Austin Allen Ellsum THOMAS died after being struck by a Volvo shovel loader truck while walking on the factory floor at a paper mill on 6 February 2017. The concerns identified were the potential distraction caused by music played at high volume in heavy machinery and the absence of random drug testing for employees operating heavy machinery, particularly drivers.
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 control high-volume music use while operating heavy machinery
Wider context from the report “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse . Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver . I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased.
(2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017.
” 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 policy governing music and CD use while operating machinery
Wider context from the report “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased.
(2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017.
” 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 review or update the drugs policy
Wider context from the report “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased.
(2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017 .
” 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 eliminate simultaneous pedestrian and vehicle movement on the factory floor
Wider context from the report “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether . The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased.
(2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017.
” 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 random drug testing for drivers operating heavy machinery
Wider context from the report “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased.
(2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only . There is no policy in relation to random testing particularly for drivers operating heavy machinery . Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths . I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017.
” Open source report
4 Oct 2018 James Ryan McLaren · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 4 Failure to ensure that locked bins can be opened from the inside View source Dark and unlit bin storage areas View source Quiet and isolated bin storage areas View source Failure to secure large commercial or communal domestic bins against entry 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
James Ryan McLaren · 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
James Ryan McLaren was found deceased at a recycling site on 24 December 2017 after he was last seen leaving a nightclub and CCTV showed him walking towards an area containing large commercial waste bins. The report raises concerns about unsecured or inadequately lit bins, the risk of people sheltering inside them, and whether bins can be opened from the inside when locked.
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 ensure that locked bins can be opened from the inside
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key, and that to unlock the bins would only take a matter of seconds, and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker, and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 Dark and unlit bin storage areas
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key, and that to unlock the bins would only take a matter of seconds, and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker , and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 Quiet and isolated bin storage areas
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key, and that to unlock the bins would only take a matter of seconds, and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker, and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 large commercial or communal domestic bins against entry
Wider context from the report “The WISH WASTE 25 – Managing access to large waste and recycling bins – contains formal guidance to prevent death or serious injury when people shelter in large commercial or communal domestic bins. This guidance was provided to the Inquest. Factors increasing the foreseeability of people gaining access and getting into the bins include, but are not limited to:
▪ the bin storage area:
• being quiet and isolated;
• being dark and unlit, especially at collection times;
▪ the bins:
• having lids that are not secured and easy to open.
I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd December 2017. I heard that where there were locks to the bins and their lids, some had a generic lock that could be opened using a generic key , and that to unlock the bins would only take a matter of seconds , and that this would not be an onerous task for an operator to unlock the bin. I also heard that, although not in the location where James climbed into the bin, some customers fitted combination locks to bins with a code shared on a manifest for the collection vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and this is also a concern. This is particularly relevant with the nights becoming colder and darker, and the potential for people to seek refuge in bins due to the elements or for any other reason.
” 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 Endorse WISH guidance as a means of managing risk, complying with the law and demonstrating industry-standard best practice.
Verbatim wording from the response “The Waste Industry Safety and Health Forum (WISH) is an industry led organisation that exists to communicate and consult with the waste and recycling industry to improve its health and safety performance. The guidance WISH produces, such as WASTE 25, Managing Access to Large Waste and Recycling Bins, is developed by the industry and HSE is consulted on the content. HSE are a member of, and advisor to, WISH but does not own the guidance that WISH produces. HSE does however endorse guidance produced by WISH as a means of managing risk, complying with the law and demonstrating best practice as industry standard.” Source location 2018-0330-Response-by-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 WASTE 25’s risk-based measures, including secure storage or suitable locks, are sufficient; a generic bin-lid lock is not required.
Verbatim wording from the response “WASTE 25 then sets the reasonable precautions that businesses can take to prevent non-employees (with the exception of collection crews) from freely accessing any bins, i.e. to keep the bin “secure”. In this context security is taken to mean preventing a person physically getting into the bin. The guidance highlights factors that could increase the potential of persons accessing commercial bins and containers – such as leaving them in an open and/or unsecured area. Businesses should consider storing their bins within their building, within the curtilage of their premises, or in a dedicated secure area/enclosure. This in itself may be sufficient to prevent access and negates the needs for individual bins to be locked. Other deterrents such as locating bins in a well-lit area will have a role to play.” Source location 2018-0330-Response-by-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 Businesses using bins must assess access risks and decide which reasonably practicable prevention measures to adopt.
Verbatim wording from the response “The guidance sets out circumstances that make it more likely that a person may try to gain access to bins taking account of location, the nature of materials collected in the bin, ease of access and so on. These are the factors that a business using such bins will need to take into account to decide what measures they need to adopt to restrict access. Where it is reasonably foreseeable that someone may access a bin the legal obligation on a user is to do what is reasonably practicable to prevent access.” Source location 2018-0330-Response-by-HSE
Open published response
28 Sep 2018 Donald Berry · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of relevant authorities to identify high voltage power lines over event sites View source Lack of nationally replicated site visits for large events View source Failure to identify high voltage power lines over event sites View source Failure to minimise risks from high voltage power lines over event sites 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
Donald Berry · 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
Donald Berry suffered severe injuries after being electrocuted while working at the Kendal Calling Festival on 22 July 2010, and died from ongoing health complications on 23 August 2016. The inquest heard concerns that a clearly visible high-voltage power line over the site had not been identified or addressed, despite an Event Safety Plan and the licensing process. It also heard that the issue had not been noted by any of the authorities involved and that site-visit arrangements were not replicated nationally.
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 relevant authorities to identify high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue . Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” 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 nationally replicated site visits for large events
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this .
” 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 identify high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” 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 minimise risks from high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” 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 Raise awareness of the incident with industry stakeholders and underline the importance of following event safety guidance.
Verbatim wording from the response “I consider that the current available guidance enables event organisers and other relevant persons and bodies to identify the risks arising from overhead power lines. I will however take the opportunity to raise awareness of this incident with industry stakeholders, underlining the importance of all people involved in event organising and planning to adhere to the standards set out in guidance.” Source location 2018-0324-Response-by-HSE_Redacted
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 web-based event safety guidance addressing risks from overhead high-voltage power lines.
Verbatim wording from the response “HSE has published web-based event safety guidance to help event organisers comply with their legal duties – see http://www.hse.gov.uk/event-safety/index.htm. The guidance helps organisers identify risks, such as those arising from contact with overhead high voltage power lines” Source location 2018-0324-Response-by-HSE_Redacted
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 responsible for enforcing health and safety law at individual events within their geographical areas.
Verbatim wording from the response “HSE leads on national occupational health and safety policy for the entertainments and leisure sector, whilst Local Authorities are responsible for enforcing the law at individual events in their geographical area. In this case, Eden Council successfully prosecuted the event organisers for breaches of the Health and Safety at Work etc. Act 1974 in March 2013.” Source location 2018-0324-Response-by-HSE_Redacted
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 Current available guidance is considered sufficient to enable event organisers and relevant bodies to identify risks from overhead power lines.
Verbatim wording from the response “I consider that the current available guidance enables event organisers and other relevant persons and bodies to identify the risks arising from overhead power lines. I will however take the opportunity to raise awareness of this incident with industry stakeholders, underlining the importance of all people involved in event organising and planning to adhere to the standards set out in guidance.” Source location 2018-0324-Response-by-HSE_Redacted
Open published response
28 Aug 2018 PETER JOHN LETT · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 2 Unguarded historic and heritage equipment View source Lack of HSE guidance for historic and heritage equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
PETER JOHN LETT · 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 9 March 2018, Peter John Lett was volunteering at Heckington Windmill when his clothing became entangled in the crankshaft of a Ruston Rornssby engine, causing fatal injuries. The inquest identified a lack of HSE guidance for historic and heritage equipment, much of which was unguarded and potentially dangerous.
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 Unguarded historic and heritage equipment
Wider context from the report “During the Inquest it became clear that there was a dearth of HSE Guidance in respect of historic and heritage equipment, much of which is unguarded and potentially extremely dangerous . Clear guidance needs to be produced by the HSE, failing which it is highly probable that further deaths will occur.
” 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 HSE guidance for historic and heritage equipment
Wider context from the report “During the Inquest it became clear that there was a dearth of HSE Guidance in respect of historic and heritage equipment , much of which is unguarded and potentially extremely dangerous. Clear guidance needs to be produced by the HSE, failing which it is highly probable that further deaths will occur.
” 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 Work with relevant stakeholders to develop guidance and support networks helping voluntary organisations find bespoke risk-control solutions, including for heritage machinery.
Verbatim wording from the response “The lead on volunteers has been incorporated into the HSE Public Services Sector. The current work plan seeks to improve and expand the specific HSE web pages which focus on voluntary activity and work with relevant stakeholders to develop further guidance and support networks for voluntary organisations including assisting them in finding bespoke guidance and risk control solutions to include heritage machinery.” Source location 2018-0356-Response-by-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 Improve and expand HSE web pages focused on voluntary activity and relevant safety guidance.
Verbatim wording from the response “The lead on volunteers has been incorporated into the HSE Public Services Sector. The current work plan seeks to improve and expand the specific HSE web pages which focus on voluntary activity and work with relevant stakeholders to develop further guidance and support networks for voluntary organisations including assisting them in finding bespoke guidance and risk control solutions to include heritage machinery.” Source location 2018-0356-Response-by-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 Existing machinery-guarding guidance and PUWER risk-assessment duties are considered sufficient for historic and heritage equipment; no separate HSE guidance is required.
Verbatim wording from the response “The Health and Safety Executive has produced a wide range of guidance relevant to the guarding of machinery. This is freely available to download from the HSE website. The machinery guarding homepage signposts readers to a wide range of additional information including specific guidance on the requirements for dangerous parts of machinery to be guarded to comply with the Provision & Use of Work Equipment” Source location 2018-0356-Response-by-HSE
Open published response
17 Jul 2018 JJ Wilson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to require fire retardant overalls for test track drivers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JJ Wilson · 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
JJ Wilson died instantaneously after a racing car he was driving during a shakedown test left the track and collided with a tree, causing serious head and neck injuries. The report raised concern that fire-retardant overalls were not required for test-track drivers, creating a potential risk of death or serious injury in a similar crash.
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 fire retardant overalls for test track drivers
Wider context from the report “The Court heard evidence that whilst there are regulations regarding clothing to be worn during race events, set by the FIA, there are no regulations for clothing to be worn whilst testing a racing car on a test track .
The Court heard evidence that JJ was wearing racing boots, gloves and a new Schuberth race helmet, but was wearing ordinary combat trousers. The Court heard evidence that racing overalls were available had JJ wanted to wear these.
Whilst ████████ for the Surrey Police Collision Investigation Unit confirmed in her evidence that JJ’s clothing would not have made any difference to the sad outcome in this case, I am concerned that fire retardant overalls are not a requirement to be worn by all test track drivers .
- It is not obligatory for fire retardant overalls to be worn by test track drivers which creates a potential risk of death or serious injury in the event of a crash in circumstances similar to that which caused the death of JJ Wilson;
Consideration should be given to whether any steps can be taken to address the above concerns.
” 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 FIA clothing requirements fall outside HSE’s remit for comment.
Verbatim wording from the response “The requirements within the FIA Regulations are outside the comment of the HSE but as said earlier FIA Sports rules and regulations are required to have notice and compliance to health and safety law and where there is a gap it is for them as the sport’s governing body to close this gap and ensure compliance.” Source location 2019-0243-Response-by-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 Any gap in FIA requirements must be closed by FIA, as the sport’s governing body, to ensure compliance with health and safety law.
Verbatim wording from the response “The requirements within the FIA Regulations are outside the comment of the HSE but as said earlier FIA Sports rules and regulations are required to have notice and compliance to health and safety law and where there is a gap it is for them as the sport’s governing body to close this gap and ensure compliance.” Source location 2019-0243-Response-by-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 UK law requiring foreseeable-risk assessment, including fire-retardant overalls, addresses the concern when requirements are implemented and instructions followed.
Verbatim wording from the response “Having reviewed the information and legislation in place, regarding the need for assessment of foreseeable risk, it is concluded that there is no gap when the applicable legislation in relation to duties and the workplace if the current requirements are implemented and instructions followed. HSE considers that no action is required because existing UK law includes the requirement to assess, along with many other risks surrounding the activity, the need for wearing of fire-retardant overalls.” Source location 2019-0243-Response-by-HSE
Open published response
2 Jan 2018 Paul Anthony Daniels · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of immediately available support for tree surgeons View source Ineffective communication between groundsmen and tree surgeons View source Failure to provide an aerial-work-qualified groundsman for tree surgeons View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Anthony Daniels · 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
Paul Anthony Daniels died after falling approximately 50 feet from a conifer tree while working as a tree surgeon at Hazel Grove Golf Club. Concerns included the staffing ratio, the groundsman’s lack of aerial-work qualification, and difficult communication between the groundsman and tree surgeons.
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 immediately available support for tree surgeons
Wider context from the report “1. There were two tree surgeons climbing with one groundsman between them. The ratio of 2:1 meant that the tree surgeons did not have someone supporting them and available immediately 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 Ineffective communication between groundsmen and tree surgeons
Wider context from the report “3. Communication between the groundsman and tree surgeons was via shouting and hand signals . This was difficult given the density of the trees being cut and the height that the tree surgeons were working at .
” 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 an aerial-work-qualified groundsman for tree surgeons
Wider context from the report “2. The groundsman supporting the tree surgeons was not qualified for aerial work . This meant that should the tree surgeon have required assistance whilst in the trees the groundsman could not have gone to their help ;
” 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 Ensure lessons from the incident are considered when AFAG 401 and AFAG 402 are next reviewed.
Verbatim wording from the response “In addition as a matter of routine AFAG and its members keep guidance under review to ensure that lessons learned through incidents are reflected in the guidance and we will ensure that these points are again considered when these specific leaflets are next reviewed.” Source location 2018-0003-Response-by-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 Promulgate incident learning and reinforce adherence to relevant tree-work safety guidance through AFAG committee members and their organisations.
Verbatim wording from the response “AFAG next meets as a committee on 8 May 2018 and I will take this opportunity to promulgate the key learning points from this incident via the committee members. The range of organisations represented on the committee should enable the message, through their respective memberships, to have a wide reach throughout the industry. I will ask that members underline the importance of all people involved in this type of work adhering to the standards set out in the guidance and highlight the concerns raised in your letter.” Source location 2018-0003-Response-by-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 AFAG guidance adequately addresses tree-climber ratios, aerial-rescue training and communication requirements for legal compliance.
Verbatim wording from the response “These three matters are addressed in long standing guidance produced by AFAG and effectively set out the standards expected to ensure legal compliance in this type of work.” Source location 2018-0003-Response-by-HSE
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