29 Aug 2017 Shaun Carter · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 6 Failure to audit compliance with dumper truck safety procedures View source Failure to ensure dumper truck safety procedures are accessible to all relevant personnel View source Failure to follow dumper truck safety procedures View source Dumper truck drivers jumping from trucks during incidents View source Lack of a process for safely managing spoil heaps View source Lack of industry standards for managing spoil heaps View source See 3 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
Shaun Carter · 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
Shaun Carter died after jumping from a dumper truck that went over the edge of a spoil heap at a construction site; he was struck by the truck and suffered catastrophic injuries. The principal concerns were that safety procedures for dumper trucks were not consistently followed, communicated or audited, that there was no process or industry guidance for safely managing spoil heaps, and that drivers may naturally jump from trucks despite instructions to remain seated.
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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 Failure to audit compliance with dumper truck safety procedures
Wider context from the report “1. At the inquest there was evidence that the risks associated with the use of dumper trucks was recognised and that risk assessments and method statements were written which reflected these risks. However the safety procedures were not followed, not seen by all relevant personnel (some of whom could not read) and the practice in this regard was not audited .
” 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 dumper truck safety procedures are accessible to all relevant personnel
Wider context from the report “1. At the inquest there was evidence that the risks associated with the use of dumper trucks was recognised and that risk assessments and method statements were written which reflected these risks. However the safety procedures were not followed, not seen by all relevant personnel (some of whom could not read) and the practice in this regard was not audited.
” 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 dumper truck safety procedures
Wider context from the report “1. At the inquest there was evidence that the risks associated with the use of dumper trucks was recognised and that risk assessments and method statements were written which reflected these risks. However the safety procedures were not followed , not seen by all relevant personnel (some of whom could not read) and the practice in this regard was not audited.
” 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 Dumper truck drivers jumping from trucks during incidents
Wider context from the report “3. Dumper trucks are designed to ensure that drivers are protected, even if the dumper trucks topple over. However the inherent open nature of trucks can nonetheless make the driver feeling vulnerable and despite the instructions which require the driver to remain seated during an incident, statistics indicate (as in this case) that the natural reaction of drivers is to jump from the truck .
” 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 process for safely managing spoil heaps
Wider context from the report “2. At the inquest it was confirmed that there was no process in place to ensure that spoil heaps were managed safely , nor any guidelines issued by the HSE in this regard. This has been addressed by Tonic Construction in relation to the site its manages, but there are still no industry standards relating to the management of spoil heaps.
” 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 industry standards for managing spoil heaps
Wider context from the report “2. At the inquest it was confirmed that there was no process in place to ensure that spoil heaps were managed safely, nor any guidelines issued by the HSE in this regard. This has been addressed by Tonic Construction in relation to the site its manages, but there are still no industry standards relating to the management of spoil heaps .
” 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 Participate in the cross-industry working group taking forward safety improvements for forward-tipping dumpers and spoil heaps.
Verbatim wording from the response “There were several fatal accidents involving forward tipping dumpers during 2016 and HSE was instrumental in helping the construction industry (including Tonic Construction) set up a working group to take forward safety improvements connected with the design and use of dumper trucks and the design of spoil heaps. I attend that group on behalf of HSE. The group is co-chaired by the Construction Plant-hire Association and Civil Engineering Contractors Association. The group comprises construction contractors, hire companies, owners of forward tipping dumpers, manufacturers, client organisations and industry federations as well as HSE.” Source location 2017-0245-Response-by-HSE
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publicise industry safety changes through the e-news bulletin and provide website links to relevant dumper and spoil-heap guidance.
Verbatim wording from the response “The actions from that group include promoting an emphasis on training, not just of operators but also of supervisors and those who design construction sites so they understand the safety issues raised by the construction of spoil heaps and can where possible reduce or eliminate the use of them and otherwise tightly control the use of them. HSE will publicise the changes via its e-news bulletin which is well subscribed to within the construction industry, and provide links to the industry pages on our website. Other specific actions the group is taking are included below.” Source location 2017-0245-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 Participate in manufacturers’ work assessing feasible and desirable forward-tipping dumper design improvements, including cab and restraint-related measures.
Verbatim wording from the response “A manufacturers’ sub-group of the working group has been considering potential dumper truck design improvements identified by the users/hire companies/clients. These result from a survey of Civil Engineers Contractors Association members which suggested improvements that are most important or critical to safety. The manufacturers will be meeting again, under the leadership of the Construction Equipment Association, to work through specific improvements that can be made. HSE will also be involved. Examining the feasibility / desirability of the fitting of cab as standard will take some time. There is currently no standard or test criteria for determining the design of any cab and the level of impact it should take. Design changes need to be considered carefully and done correctly so that they do not introduce other unforeseen hazards.” Source location 2017-0245-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 Comment on the updated guidance for safe use of forward-tipping dumpers.
Verbatim wording from the response “The Construction Plant-hire Association (CPA) is producing updated guidance on the safe use of forward tipping dumpers. HSE has been involved in commenting on this. This work is nearing completion and the guidance will be available free to download from the CPA website. The guidance will include information for operators that should improve awareness and knowledge by including detail explaining why issues are important rather than just saying something should be done; guidance to managers and designers for planning and supervision of forward tipping dumpers on sites; and a case study annex using a real example. HSE will provide a link from its website to this guidance.” Source location 2017-0245-Response-by-HSE
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise HSG144 guidance, including advice and signposting on forward-tipping dumper safety.
Verbatim wording from the response “HSE has started a review and revision of its HSG144 guidance on safe use of vehicles on construction sites. We are considering what specific advice we can provide to help improve safety in the use of forward tipping dumper trucks and include signposting to other guidance published by CPA and CECA. This should be completed next year.” Source location 2017-0245-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 Assist with adding advice on unconsolidated spoil heaps to industry guidance produced under the Strategic Forum for Plant Safety Group.
Verbatim wording from the response “The Strategic Forum for Plant Safety Group (SFPSG) is to produce good practice guidance on forward tipping dumpers. I also attend this group on behalf of HSE. This guidance will be available to download free of charge and will be hosted on the CPA website (CPA chair that group). I will also be assisting CPA with an addition to its guidance on ground conditions to include advice on unconsolidated spoil heaps, and this will again be under the auspices of the SFPSG. This guidance will also be available to download free of charge from the CPA website.” Source location 2017-0245-Response-by-HSE
Open published response
24 Jul 2017 GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4 Visitors’ language difficulties and lack of experience with the sea View source Failure to maintain effective public communication about coastal safety View source Lack of formal governance and control of coastal risk management View source Insufficient education and awareness of coastal dangers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
GUSTAVO SILVA DA CRUZ and 6 others · 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 24 June 2016, Gustavo Silva da Cruz and Mohit Dupar entered the sea at Camber Sands; Da Cruz's body was later washed ashore, and Dupar was brought unconscious to the beach and died at Ashford Hospital on 28 July 2016. On 24 August 2016, five young Sri Lankan men entered the sea as the tide came in and all died, with their bodies recovered that day or after the tide receded. The report raises concerns about the lack of formal governance and risk management for beach safety, including lifeguard provision, public education, communication, resources, and whether restrictions on beach use should be considered.
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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 Visitors’ language difficulties and lack of experience with the sea
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea . The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective public communication about coastal safety
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process ,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 governance and control of coastal risk management
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements . Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime , given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea.
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” 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 education and awareness of coastal dangers
Wider context from the report “(b) There appears to be no formal governance or control of risk management requirements. Should the present, virtually voluntarily, structure be examined? Could perhaps the Marine and Coastguard Agency, who have enforcement powers akin to those of the Police, be given more resources and take a bigger role than they currently have? The problem is an increasing one. The evidence suggested that on a pleasant hot summer’s day 25,000 to 30,000 people visit Camber Sands, many of whom have language difficulties and do not speak much English, and many others of whom have no experience of going into the sea. The question is whether leaving matters to a charity is really the best basis of a structure intended to spearhead a possibly overdue attempt to modernise, harmonise, and improve the safety regime, given so many changes at Camber.
(c) Changes include:-
(i) possible climate change effects,
(ii) differences in ethnic origins and language spoken by current visitors,
(iii) constant and fast changes in means of communication with the public, which everybody at these inquests agreed to be crucial to the necessary educative process,
(iv) improvement, considered vital, of education and awareness of coastal dangers amongst children and those who live far from the sea .
(d) Inevitably resource and monetary considerations affect decision making by those charged with safeguarding people like the seven who died here. Perhaps that is another reason why a review of the current system may well be needed.
” Open source report
3 Mar 2017 Alan Walsh · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Risk of ladder spigots being inadvertently sheared off during premature opening View source Lack of awareness of ladder spigot safety role and shearing risk during premature opening View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Alan Walsh · 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
Alan Walsh fell from a 2.5-metre ladder while inspecting a fault in a ceiling void at Eltham Leisure Centre and died the same day from injuries sustained in the fall. The report raised concern about a lack of awareness of the safety-critical role of the ladder’s spigots and the possibility that they could be inadvertently sheared off, although their absence was not found to have caused the accident.
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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 Risk of ladder spigots being inadvertently sheared off during premature opening
Wider context from the report “There would appear not be awareness of the safety critical role of the spigots on this ladder, nor the fact that they can easily and inadvertently be sheared off, on premature opening of the ladder . Whilst the absence of these spigots was not found to be the cause of this accident, they may have had a role in the injuries sustained and the implications of the lack of awareness may create risks to health and safety.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of ladder spigot safety role and shearing risk during premature opening
Wider context from the report “There would appear not be awareness of the safety critical role of the spigots on this ladder, nor the fact that they can easily and inadvertently be sheared off, on premature opening of the ladder . Whilst the absence of these spigots was not found to be the cause of this accident, they may have had a role in the injuries sustained and the implications of the lack of awareness may create risks to health and safety .
” Open source report
14 Feb 2017 David Ivor Alexander · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 8 Lack of industry guidance on hydraulic ram bracket overturns View source Lack of widespread industry recognition of gradient-related overturn risk View source Overturn hazard in the relevant section of the industry View source Lack of a requirement to report overturns View source Failure to fit or use inclinometers on articulated lorries View source Failure to carry out post-event investigations of overturns View source Lack of regular inspection and replacement schedules for hydraulic ram brackets View source Overturn hazard from gradients over 2 degrees during fully loaded full hydraulic-ram extension 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.
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AI-generated summary
David Ivor Alexander · 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
David Ivor Alexander, an experienced lorry driver and mechanic, was killed instantly when a loaded trailer overturned onto him during the unloading of animal feed. Concerns included limited understanding and reporting of overturns, inadequate industry guidance and inspection practices for hydraulic ram brackets, and the lack of routine use of inclinometers despite the risk posed by slight gradients.
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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 industry guidance on hydraulic ram bracket overturns
Wider context from the report “(3) There is little or no industry guidance available relating to this issue
” 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 widespread industry recognition of gradient-related overturn risk
Wider context from the report “(4) It is not standard to fit new articulated lorries with inclinometers and they are not routinely, if ever, used on older vehicles notwithstanding that it is recognised that a very slight gradient of over 2 degrees can (at full extension of the hydraulic ram when fully loaded) cause overturn. This information does not appear to be widely recognised within the industry .
” 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 Overturn hazard in the relevant section of the industry
Wider context from the report “(1) Evidence was taken during the inquest that overturns are not uncommon in this particular section of the industry , but are infrequently reported as there is no requirement to do so
” 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 requirement to report overturns
Wider context from the report “(1) Evidence was taken during the inquest that overturns are not uncommon in this particular section of the industry, but are infrequently reported as there is no requirement to do so
” 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 fit or use inclinometers on articulated lorries
Wider context from the report “(4) It is not standard to fit new articulated lorries with inclinometers and they are not routinely, if ever, used on older vehicles notwithstanding that it is recognised that a very slight gradient of over 2 degrees can (at full extension of the hydraulic ram when fully loaded) cause overturn. This information does not appear to be widely recognised within the industry.
” 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 carry out post-event investigations of overturns
Wider context from the report “(2) The cause/s of overturn are not well understood or recognised as post event investigations are not carried out and there appears to be little knowledge or industry practise regarding regular inspections and/or replacement schedules in respect of the hydraulic ram brackets
” 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 regular inspection and replacement schedules for hydraulic ram brackets
Wider context from the report “(2) The cause/s of overturn are not well understood or recognised as post event investigations are not carried out and there appears to be little knowledge or industry practise regarding regular inspections and/or replacement schedules in respect of the hydraulic ram brackets
” 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 Overturn hazard from gradients over 2 degrees during fully loaded full hydraulic-ram extension
Wider context from the report “(4) It is not standard to fit new articulated lorries with inclinometers and they are not routinely, if ever, used on older vehicles notwithstanding that it is recognised that a very slight gradient of over 2 degrees can (at full extension of the hydraulic ram when fully loaded) cause overturn . This information does not appear to be widely recognised within the industry.
” Open source report
14 Nov 2016 Mr Benjamin Hugh Wylie · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 9 Unavailability of a quick-reference condensed operator manual View source Inadequate training in correct track-greasing procedures View source Lack of permanent warning signage beside the grease nipple View source Failure to issue existing users a warning bulletin about grease nipple failure risks View source Failure of the manual to prohibit repairs or modifications to failed parts View source Existing machines requiring removal of the metal plate for track greasing View source Lack of pressure release valves within the grease nipple unit View source Grease nipple orientation facing the greasing operator View source Failure of the manual to require replacement of failed parts with new units View source See 6 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
Mr Benjamin Hugh Wylie · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Benjamin Hugh Wylie, a 24-year-old man, died after a grease nipple detached while he was tensioning the tracks of a piling rig on a building site, expelling high-pressure grease that caused fatal injuries. Concerns included the machine’s design and pressure-release features, inadequate warnings and guidance, repair and maintenance practices, and possible deficiencies in worker training.
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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 Unavailability of a quick-reference condensed operator manual
Wider context from the report “(6) It was heard that the manual for the SR70 piling rig machine is always kept in the cab of the machine for use by the operator. This was described as a 350 page manual. No quick reference condensed version of key matters is available.
” 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 training in correct track-greasing procedures
Wider context from the report “(8) The evidence suggested that certain piling rig workers were not following the correct procedures for greasing the tracks suggesting that there was a training issue that needed to be addressed and possibly incorporated into the manual.
” 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 permanent warning signage beside the grease nipple
Wider context from the report “(1) In the course of the evidence at the Inquest it was acknowledged that the risk of grease being expelled from the grease nipple at high pressure was recognised. No permanent warning plate or sign was attached to the machine beside the grease nipple.
” 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 issue existing users a warning bulletin about grease nipple failure risks
Wider context from the report “(5) It is understood that no warning bulletin has been issued to existing users of the relevant piling rig machines warning of the risk of the grease nipple failure and potential consequences.
” 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 manual to prohibit repairs or modifications to failed parts
Wider context from the report “(7) The manual does not contain a warning to always replace failed parts on piling rigs with new units. There is no statement that repairs or modifications to failed parts should not be carried out.
” 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 Existing machines requiring removal of the metal plate for track greasing
Wider context from the report “(4) The Jury heard that, in the ordinary course of use of the machine, were covered by a metal plate. However, this had to be removed in order to carry out the greasing of the tracks . Evidence was given that new machines allow greasing of the tracks with the plate in place but there are a number of existing machines in use which do not have that adaptation.
” 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 pressure release valves within the grease nipple unit
Wider context from the report “(3) The evidence also given was that other piling rig manufacturers install pressure release values within the grease nipple unit that prevents pressure building up to the force that struck Ben Wylie.
” 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 Grease nipple orientation facing the greasing operator
Wider context from the report “(2) The grease nipple(s) of which there is one on each side of the machine was orientated on the SR70 machine so that it was perpendicular to, rather than parallel to, the tracks. This meant that the nipple faced out towards the greasing operator. Evidence suggested that other manufacturers have the grease nipple orientated parallel to the tracks.
” 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 manual to require replacement of failed parts with new units
Wider context from the report “(7) The manual does not contain a warning to always replace failed parts on piling rigs with new units. There is no statement that repairs or modifications to failed parts should not be carried out.
” 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 Issue a detailed Safety Alert addressing grease-nipple component suitability, protective plates, damaged-component reuse and training for track tensioning.
Verbatim wording from the response “body. However, the opinion of its relevant Specialist Inspector of Mechanical Engineering is that the critical issue is to ensure that the parts specified are suitable for expected operating pressures so as to ensure failure is prevented, so far as is reasonably practicable. HSE intends to address this issue in a further Safety Alert to be issued to industry, which is currently in draft form.” Source location 2016-0407-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 Issue a general Safety Alert on the circumstances of the incident to relevant industry users.
Verbatim wording from the response “In 2015 HSE issued a general Safety Alert relating to the circumstances of the incident which led to Mr Wylie’s death. HSE is aware that Soilmec (UK) Ltd have issued two Safety Alerts relevant to the incident which occurred with one of their machines. Following conclusion of the Inquest HSE has been preparing a more detailed Safety Alert, taking account of further evidence and the results of component testing which became available after the issue of its first general Safety Alert. The new Safety Alert is due to be published shortly. It is aimed at a broad audience which will include those working in the piling industry, but also those working in other industries where the use of tracked plant is commonplace. Please let me know whether you would like me to send you a copy of the Safety Alert when it is issued.” Source location 2016-0407-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 Machinery law does not generally require warnings directly on machine parts, except to prevent incorrect fitting or illustrate rotation.
Verbatim wording from the response “HSE notes that other respondents have stated that a warning sticker/plate will be affixed to machines adjacent to track tensioning grease nipples in the future. The legislation which machine manufacturers are required to comply with when designing, manufacturing and supplying machinery for use at work, the Supply of Machinery (Safety) Regulations 2008 (SMR) require that risks be eliminated by design wherever possible. Where the designer considers that residual risks exist that cannot be designed out, the Regulations state that necessary warnings must be provided. This allows the manufacturer to choose whether to place warnings that will be needed less frequently in the operation and maintenance manual and/or to affix a warning to the machine part itself.” Source location 2016-0407-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 The wording of the machine manual is for the manufacturer to determine, subject to its legal obligation to provide safe operating information.
Verbatim wording from the response “The legal requirement under SMSR is for manufacturers to provide “the information necessary to operate it [ie the machine] safely, such as instructions.”” Source location 2016-0407-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 Employers and contractors must determine required competence and ensure workers are properly trained for machinery maintenance operations.
Verbatim wording from the response “There are several legal requirements on employers and contractors to ensure that those who operate or maintain machinery used on construction sites or elsewhere are properly trained and competent to carry out both scheduled and unplanned maintenance operations. Those with duties under health and” Source location 2016-0407-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 No research is planned into grease nipple assembly designs because additional devices may introduce risks and other risk-reduction means are preferable.
Verbatim wording from the response “The opinion of HSE’s relevant Specialist Inspector of Mechanical Engineering is that if a valve, designed to dissipate pressures well below component failure design pressures, were fitted within the grease nipple assembly, failure of an undamaged grease nipple would be very unlikely. However, HSE notes the differing opinions of the members of the FPS regarding the possibility of other risks being created through the fitting of such devices. When designing machinery, especially where it will be operating in harsh environments, one consideration would be to minimise the number of small devices which could fail or be incorrectly adjusted or replaced. Eliminating or reducing associated risks by other means would generally be preferable. HSE has no plans to conduct research into the designs of grease nipple assemblies.” Source location 2016-0407-Response-by-HSE
Open published response
15 Sep 2016 Marko Petrovic · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of written guidelines for dismantling cantilevered scaffolds View source Failure to require a RAMS for dismantling scaffolding 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
Marko Petrovic · 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
Marko Petrovic died from multiple injuries after a cantilever scaffolding platform became unstable and fell from the roof of Calderdale Royal Hospital while it was being dismantled on 11 January 2016. Concerns included the absence of written guidelines for dismantling cantilevered scaffolds and the lack of a specific risk assessment and method statement for dismantling the scaffolding.
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 written guidelines for dismantling cantilevered scaffolds
Wider context from the report “During the inquest evidence was heard to suggest that there are no written guidelines with respect to the dismantling of cantilevered scaffolds .
• During the inquest evidence was heard to suggest that there are currently no written guidelines with respect to dismantling of cantilevered scaffolds . In this respect I would ask that the consideration be given to a further review of the existing guidelines.
• Although evidence was heard to suggest that a RAMS had been initiated with respect to the erection of the scaffolding, a further RAMS to cover the subsequent dismantlement of the scaffolding was not required. I would ask that consideration be given to the appropriateness of further RAMS specific to the dismantlement of the scaffolding.
” 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 a RAMS for dismantling scaffolding
Wider context from the report “During the inquest evidence was heard to suggest that there are no written guidelines with respect to the dismantling of cantilevered scaffolds.
• During the inquest evidence was heard to suggest that there are currently no written guidelines with respect to dismantling of cantilevered scaffolds. In this respect I would ask that the consideration be given to a further review of the existing guidelines.
• Although evidence was heard to suggest that a RAMS had been initiated with respect to the erection of the scaffolding, a further RAMS to cover the subsequent dismantlement of the scaffolding was not required . I would ask that consideration be given to the appropriateness of further RAMS specific to the dismantlement of the scaffolding.
” Open source report
13 Sep 2016 Zane Ilorie Christopher Yusuf GBANGBOLA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Inadequacy and inaccuracy of safety guidance for internal-combustion-engine equipment used in confined or enclosed areas View source Use of HSE logos or equivalent representations creating an appearance of endorsement of unendorsed guidance 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
Zane Ilorie Christopher Yusuf GBANGBOLA · 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
Zane Ilorie Christopher Yusuf GBANGBOLA, aged seven, died on 7 February 2014 after exposure to carbon monoxide from a petrol-driven pump used during severe flooding at his family home. The report raised concerns that HAE safety guidance for internal-combustion-engine equipment used in confined areas was inadequate and potentially misleading, and that the use of HSE branding could be interpreted as endorsement of the guidance.
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 Inadequacy and inaccuracy of safety guidance for internal-combustion-engine equipment used in confined or enclosed areas
Wider context from the report “I am concerned that the Safety Guidance documents currently prepared by HAE in relation to equipment that is driven by an internal combustion engine, where there is a realistic risk that that equipment might be used in confined areas, are inadequately and potentially misleading . Further, that the use of the HSE logo, in whatever form it might appear, runs the risk of being interpreted by someone reading the document as being an endorsement by the HSE of the document and its contents, thereby exacerbating the potential risk of harm by increasing that person’s confidence in the guidance albeit that the guidance may be poor.
a. The adequacy and accuracy of the Safety Guidance documents prepared by HAE for their members, not only in relation to this centrifugal pump, but in relation to any piece of equipment that is powered by an internal combustion engine where there is a realistic prospect that that piece of equipment might be used in an enclosed area.
b. The use of the HSE logo on documents that are prepared for general use by trades people and members of the public alike, whether that be the official HSE logo or whether it be in the form of an HSE banner Consideration should be given to taking steps to ensure that the use of any such logo, banner or equivalent representation of the HSE emblem does not give the appearance of the guidance within that document having been endorsed by the HSE when in fact it has not been.
” 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 Use of HSE logos or equivalent representations creating an appearance of endorsement of unendorsed guidance
Wider context from the report “I am concerned that the Safety Guidance documents currently prepared by HAE in relation to equipment that is driven by an internal combustion engine, where there is a realistic risk that that equipment might be used in confined areas, are inadequately and potentially misleading. Further, that the use of the HSE logo, in whatever form it might appear, runs the risk of being interpreted by someone reading the document as being an endorsement by the HSE of the document and its contents , thereby exacerbating the potential risk of harm by increasing that person’s confidence in the guidance albeit that the guidance may be poor.
a. The adequacy and accuracy of the Safety Guidance documents prepared by HAE for their members, not only in relation to this centrifugal pump, but in relation to any piece of equipment that is powered by an internal combustion engine where there is a realistic prospect that that piece of equipment might be used in an enclosed area.
b. The use of the HSE logo on documents that are prepared for general use by trades people and members of the public alike, whether that be the official HSE logo or whether it be in the form of an HSE banner Consideration should be given to taking steps to ensure that the use of any such logo, banner or equivalent representation of the HSE emblem does not give the appearance of the guidance within that document having been endorsed by the HSE when in fact it has not been.
” Open source report
10 Aug 2016 Ben Andrew Collins · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Lack of defined servicing intervals for Suction Excavation control panels View source Lack of HSE guidance on the use of Suction Excavation machines View source Failure to ensure personnel are trained to operate Suction Excavation equipment in emergencies View source Failure to provide a fully trained second operator at each excavation 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
Ben Andrew Collins · 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
Ben Andrew Collins was trapped and killed while using a suction excavation machine to excavate a trench beside the M3 Motorway on 27 July 2015. The inquest recorded positional asphyxia, fractured ribs and a fractured femur, with the jury concluding accidental death. Concerns included inadequate emergency operating knowledge and training, the absence of HSE guidance on suction excavation equipment, and servicing and documentation of control panels.
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 defined servicing intervals for Suction Excavation control panels
Wider context from the report “During the course of the inquest the evidence revealed that upon finding Mr Collins in the trench, those present had no knowledge of how to operate the Suction Excavator in order to release Mr Collins. Digsafe Excavations Ltd provided one person with knowledge of how to operate the excavator with an expectation that a second man would be provided by whosoever contracted with them. That person however would not know how to operate the Suction Excavator in an emergency or be fully trained in its use. Further there is no HSE guidance covering;
a) the use of a Suction Excavation machine,
b) training for such use,
c) the provision of a fully trained second man,
d) the regularity of servicing of control panels.
Digsafe Suction Excavation Ltd give consideration to the provision of a second man by them at each excavation who is fully trained in the operation of the Suction Excavator and associated equipment such as an air-lance.
The HSE give consideration to the provisions of guidance regarding training and the use of suction excavation equipment including a recommendation for the provision of a second man fully trained to use the Suction Excavator and associated equipment, regular servicing of remote controllers together with the proper documentation of such.
” 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 on the use of Suction Excavation machines
Wider context from the report “During the course of the inquest the evidence revealed that upon finding Mr Collins in the trench, those present had no knowledge of how to operate the Suction Excavator in order to release Mr Collins. Digsafe Excavations Ltd provided one person with knowledge of how to operate the excavator with an expectation that a second man would be provided by whosoever contracted with them. That person however would not know how to operate the Suction Excavator in an emergency or be fully trained in its use. Further there is no HSE guidance covering;
a) the use of a Suction Excavation machine,
b) training for such use,
c) the provision of a fully trained second man,
d) the regularity of servicing of control panels.
Digsafe Suction Excavation Ltd give consideration to the provision of a second man by them at each excavation who is fully trained in the operation of the Suction Excavator and associated equipment such as an air-lance.
The HSE give consideration to the provisions of guidance regarding training and the use of suction excavation equipment including a recommendation for the provision of a second man fully trained to use the Suction Excavator and associated equipment, regular servicing of remote controllers together with the proper documentation of such.
” 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 personnel are trained to operate Suction Excavation equipment in emergencies
Wider context from the report “During the course of the inquest the evidence revealed that upon finding Mr Collins in the trench, those present had no knowledge of how to operate the Suction Excavator in order to release Mr Collins . Digsafe Excavations Ltd provided one person with knowledge of how to operate the excavator with an expectation that a second man would be provided by whosoever contracted with them. That person however would not know how to operate the Suction Excavator in an emergency or be fully trained in its use. Further there is no HSE guidance covering;
a) the use of a Suction Excavation machine,
b) training for such use,
c) the provision of a fully trained second man,
d) the regularity of servicing of control panels.
Digsafe Suction Excavation Ltd give consideration to the provision of a second man by them at each excavation who is fully trained in the operation of the Suction Excavator and associated equipment such as an air-lance.
The HSE give consideration to the provisions of guidance regarding training and the use of suction excavation equipment including a recommendation for the provision of a second man fully trained to use the Suction Excavator and associated equipment, regular servicing of remote controllers together with the proper documentation of such.
” 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 a fully trained second operator at each excavation
Wider context from the report “During the course of the inquest the evidence revealed that upon finding Mr Collins in the trench, those present had no knowledge of how to operate the Suction Excavator in order to release Mr Collins. Digsafe Excavations Ltd provided one person with knowledge of how to operate the excavator with an expectation that a second man would be provided by whosoever contracted with them. That person however would not know how to operate the Suction Excavator in an emergency or be fully trained in its use. Further there is no HSE guidance covering;
a) the use of a Suction Excavation machine,
b) training for such use,
c) the provision of a fully trained second man,
d) the regularity of servicing of control panels.
Digsafe Suction Excavation Ltd give consideration to the provision of a second man by them at each excavation who is fully trained in the operation of the Suction Excavator and associated equipment such as an air-lance.
The HSE give consideration to the provisions of guidance regarding training and the use of suction excavation equipment including a recommendation for the provision of a second man fully trained to use the Suction Excavator and associated equipment , regular servicing of remote controllers together with the proper documentation of such.
” 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 the Construction Plant-hire Association and industry representatives to develop guidance on suction excavator operation, training, two-person working, maintenance and inspection records.
Verbatim wording from the response “GUIDANCE – HSE publishes a wide range of health and safety guidance written for use by industry and interested parties. For more technical or targeted guidance HSE now finds that it is more effective to assist industry trade bodies to write their own guidance. This allows the guidance to be more relevant and specific to users, easier to keep up to date and to access. The HSE has been working closely with the Construction Plant-hire Association (CPA) to improve its guidance regarding the use of suction excavators. The CPA has formed a Suction and Vacuum Excavator interest group, which comprises of representatives from the HSE, manufacturers, users and hire companies. The main thrust of the group is to produce guidance. At the time of writing this has reached the stage of a second draft which is out for consultation within the group.” Source location 2016-0282-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 The forthcoming industry guidance and accredited training scheme are considered sufficient to cover the Coroner’s identified safety concerns.
Verbatim wording from the response “It is the HSE’s opinion that the new guidance, once published; and the new accredited training scheme, once established, will cover the key points raised by the HM Coroner.” Source location 2016-0282-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 Targeted suction-excavator guidance is more appropriately produced by industry trade bodies, with HSE assistance, rather than directly by HSE.
Verbatim wording from the response “GUIDANCE – HSE publishes a wide range of health and safety guidance written for use by industry and interested parties. For more technical or targeted guidance HSE now finds that it is more effective to assist industry trade bodies to write their own guidance. This allows the guidance to be more relevant and specific to users, easier to keep up to date and to access. The HSE has been working closely with the Construction Plant-hire Association (CPA) to improve its guidance regarding the use of suction excavators. The CPA has formed a Suction and Vacuum Excavator interest group, which comprises of representatives from the HSE, manufacturers, users and hire companies. The main thrust of the group is to produce guidance. At the time of writing this has reached the stage of a second draft which is out for consultation within the group.” Source location 2016-0282-Response-by-HSE
Open published response
10 May 2016 Peter William RICHARDSON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to record lift tolerance levels for comparison by subsequent examiners View source Failure to record vehicle-lift operator training View source Failure to ensure lift users are appropriately competent to maintain the lift View source Lack of formal guidance on safe tolerances for safety-critical elements of two-post lifts View source Failure to provide guidance on required torque for safety-critical elements of Bendpak two-post lifts View source Use of foreign objects between two-post lift pads and vehicles during lifting View source Failure to provide guidance on safe tolerance levels for supplied two-post lifts View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter William RICHARDSON · 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 27 September 2015, Peter William Richardson was working beneath a car on a two-post vehicle lift when the car became dislodged and fell onto him, causing fatal head injuries. The substantive concerns included the absence of formal guidance on safe tolerances and torque levels for safety-critical lift components, inadequate recording and training arrangements, and the practice of placing foreign objects between lift pads and vehicles to provide clearance.
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 record lift tolerance levels for comparison by subsequent examiners
Wider context from the report “c) Safe tolerance should be considered at a LOLER ‘Thorough Examination’ however there is no guidance to be followed and there is no requirement for such tolerance levels to be recorded and as such the levels are not available to any subsequent examiner .
” 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 vehicle-lift operator training
Wider context from the report “d) Mr Richardson who operated the lift only received training on the specific lift at the point it was installed in 2012. All other users were subsequently trained by him in its use, which was not recorded and all users of the lift were expected to maintain the lift properly.
” 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 lift users are appropriately competent to maintain the lift
Wider context from the report “d) Mr Richardson who operated the lift only received training on the specific lift at the point it was installed in 2012. All other users were subsequently trained by him in its use, which was not recorded and all users of the lift were expected to maintain the lift properly .
” 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 guidance on safe tolerances for safety-critical elements of two-post lifts
Wider context from the report “a) No formal guidance exists as to safe tolerances of safety critical elements of two-post lifts . The Court heard from two HSE witnesses and a ‘Thorough examiner’ who examined the lift for the purposes of complying with LOLER 1988, who gave differing views on what was a safe tolerance or ‘play’ for an extended lift arm . Further, it was accepted that this was an issue of concern to the HSE, but as yet remained to be dealt with.
” 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 guidance on required torque for safety-critical elements of Bendpak two-post lifts
Wider context from the report “b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not supply guidance as to the required torque for safety critical elements of their two-post lifts and neither do they provide guidance on safe tolerance levels.
” 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 Use of foreign objects between two-post lift pads and vehicles during lifting
Wider context from the report “e) It is a known practice for a variety of different objects (for example a piece of wood) to be placed on top of the lift pads between the pad and the vehicle when it is lifted in order to provide clearance and to assist with difficult jobs such as removing a car under-shield.
” 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 guidance on safe tolerance levels for supplied two-post lifts
Wider context from the report “b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not supply guidance as to the required torque for safety critical elements of their two-post lifts and neither do they provide guidance on safe tolerance levels .
” 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 Issue and disseminate additional operational guidance requiring thorough examiners to check post-ramp door locking and lateral arm movement limits.
Verbatim wording from the response “The HSE intends to issue additional guidance concerning the inspection of two post ramps by thorough examiners to highlight the risks in relation to this type of lifting equipment. This will be covered in HSE Operational Guidance, which will be brought to the attention of the various stakeholder groups, namely the inspection industry and will also be publically available on the HSE website.” Source location 2017-0162-Response-by-HSE
Open published response
23 Mar 2016 Alan George DIMBLEBY · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 HSE guidance suggesting that operator seat restraints may not be needed or are inappropriate for self-propelled sprayers View source Lack of appropriate operator seat restraints on self-propelled sprayers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan George DIMBLEBY · 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 23 July 2015, Alan George Dimbleby died after a self-propelled crop sprayer became unstable and rolled down a steep slope, throwing him from the cabin. The jury found that the slope gradient and absence of a seatbelt materially contributed to his death. The report raised concerns about the absence of operator seat restraints on self-propelled sprayers and related HSE guidance.
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 HSE guidance suggesting that operator seat restraints may not be needed or are inappropriate for self-propelled sprayers
Wider context from the report “Operator Seat Restraint
1. Consideration should be given to fitting operator seat restraints to self-propelled sprayers. The cabin of the vehicle was such that it would have provided adequate protection to Mr Dimbleby had he not been thrown out of the vehicle. However, without appropriate operator seat restraints there is a serious risk that the operator will be thrown from the vehicle should it overturn and, as such, a safe cabin does not provide adequate protection.
2. Consideration should be given to removing self-propelled sprayers from the class of vehicles in respect of which the HSE guidance suggests that operator seat restraints may not be needed or are inappropriate [Agriculture Information Sheet 37 (revision1)].
” 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 appropriate operator seat restraints on self-propelled sprayers
Wider context from the report “Operator Seat Restraint
1. Consideration should be given to fitting operator seat restraints to self-propelled sprayers. The cabin of the vehicle was such that it would have provided adequate protection to Mr Dimbleby had he not been thrown out of the vehicle. However, without appropriate operator seat restraints there is a serious risk that the operator will be thrown from the vehicle should it overturn and, as such, a safe cabin does not provide adequate protection .
2. Consideration should be given to removing self-propelled sprayers from the class of vehicles in respect of which the HSE guidance suggests that operator seat restraints may not be needed or are inappropriate [Agriculture Information Sheet 37 (revision1)].
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise seat-restraint concerns at the next appropriate agricultural machinery safety standards meeting for consideration in future revisions.
Verbatim wording from the response “HSE works with the relevant British Standards (BSI) and European Standards (CEN) committees on agricultural machinery safety, and we will raise this issue at the next appropriate meeting for the consideration in future revisions of the applicable standards.” Source location Alan-DIMBLEBY-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider revising HSE guidance wording to better inform vehicle choice when working on slopes.
Verbatim wording from the response “On your second point, concerning HSE guidance on the use of seat restraints, similar constraints apply to how far this can be changed. Our guidance has to apply to the full range of self-propelled work equipment (including those fitted with ROPS and those not fitted with ROPS). It gives advice on the steps that should be taken to comply with health and safety legislation. The guidance is not intended to be comprehensive, and does not cover every possible configuration of self-propelled work equipment. Very specifically we cannot recommend the use of seat restraints for a vehicle that is not also fitted with a ROPS for the reasons given above. We do nonetheless keep all of our guidance under review and at the next opportunity we will consider whether the wording can be revised to better inform the choice of vehicle when working on slopes.” Source location Alan-DIMBLEBY-Response
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 Universal seat restraints cannot be advocated because restraints may increase overturn injury risk where sprayers lack suitable ROPS.
Verbatim wording from the response “On the first issue, the use of seat restraints has to be considered in conjunction with the design of the machine. If a seat restraint is to be effective in an overturn situation it must be in conjunction with a roll over protective structure (ROPS). A ROPS is a protective structure intended to provide the operator with a protective zone to reduce the risk of injury. Vehicles fitted with ROPS are fitted with seat restraints so that the operator remains within the protective zone. In 2009 the relevant standard was revised and required seat belt anchorage points if the sprayer was fitted with ROPS. However the standard, which was most recently revised in 2013, allows the manufacturer to choose how to reduce the risk of an overturn, or to mitigate the likelihood of injury in an overturn and ROPS is only one of the options” Source location Alan-DIMBLEBY-Response
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 Guidance cannot recommend seat restraints for non-ROPS vehicles because restraints may increase injury risk during overturns.
Verbatim wording from the response “Where a non-ROPS cab is present, which is particularly likely on older machines, the fitting and wearing of seat restraints is not recommended as it can increase the risk of injury in the event of a roll over. A non-ROPS cab is not designed to, nor will it have been tested to demonstrate that it can, withstand the forces to which it is exposed during a roll over. Consequently, in an overturn, the structure is likely to deform and fail, and penetrate the zone occupied by the restrained driver resulting in a risk of serious personal injury. Additionally, on older machines regardless of whether or not they have ROPS fitted, there may not be any suitable anchorage points for seat restraints and fitting them may be unfeasible.” Source location Alan-DIMBLEBY-Response
Open published response
Concerns raised 2 Lack of auditory warnings for opening rear lift doors View source Lack of visual markings distinguishing rear lift doors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Belinda Jane Wise · 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
Belinda Jane Wise fell backwards when the unmarked rear doors of a lift opened, striking her head. She later developed a large subdural haemorrhage and died five days later. The principal concern was that the lift had no signs or auditory warnings indicating that the rear doors would open, and consideration was given to making the doors more distinguishable and providing an audible warning.
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 auditory warnings for opening rear lift doors
Wider context from the report “It was a finding of the jury that there were no signs or auditory warnings within the lift to indicate that the rear doors would open . Evidence taken from the Sainsbury's store and from the Borough Council investigation confirmed that such warnings are not standard or mandatory . In this instance, it was clear from the evidence that the deceased did not appreciate that the part of the lift that she was leaning was actually the rear doors, as they were not marked in any way.
Further consideration should be given to the possibility of making the doors more apparent and distinguishable from the rest of the interior, and also to the sounding of a warning message (that may assist visually impaired passengers).
” 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 visual markings distinguishing rear lift doors
Wider context from the report “It was a finding of the jury that there were no signs or auditory warnings within the lift to indicate that the rear doors would open . Evidence taken from the Sainsbury's store and from the Borough Council investigation confirmed that such warnings are not standard or mandatory. In this instance, it was clear from the evidence that the deceased did not appreciate that the part of the lift that she was leaning was actually the rear doors, as they were not marked in any way .
Further consideration should be given to the possibility of making the doors more apparent and distinguishable from the rest of the interior, and also to the sounding of a warning message (that may assist visually impaired passengers).
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation New legislation is not being proposed at this stage because there is insufficient evidence, including no known similar incidents.
Verbatim wording from the response “Any new UK legislation would need to be evidentially based to satisfy the Secretary of State and UK stakeholders. The Health and Safety Executive (HSE) is not aware of any previous incidents of this nature. We have also discussed the matter with the UK lift industry and key users and they are also unaware of any similar incidents. The HSE is therefore not proposing to introduce new UK legislation in this matter at this stage.” Source location Belinda-Wise-Response
Open published response
27 Oct 2015 Ms. Scarlett Jukes · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Failure to require compliant protective headgear for hunt staff riding horses during employment View source MFHA recommendations permitting hunt staff to choose non-compliant protective headgear View source Failure to require compliant protective headgear for public participants in hunting 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
Ms. Scarlett Jukes · 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
Ms. Scarlett Jukes was thrown from a horse during a trail hunting event after the horse lost its footing, and her head struck the road after her riding hat came off. She suffered a severe traumatic head injury, underwent surgery, and died in hospital on 14 February 2015. The principal concerns were that participants and hunt staff were not required to wear protective headgear complying with recognised safety standards, and that hunt staff could choose to wear non-compliant traditional hunt caps.
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 compliant protective headgear for hunt staff riding horses during employment
Wider context from the report “(2) Hunt staff who are paid employees of each hunt and whose work can involve significant time riding horses are not required to wear head gear designed and manufactured to recognised safety standards.
” 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 MFHA recommendations permitting hunt staff to choose non-compliant protective headgear
Wider context from the report “(3) The current recommendations of the Master of Foxhounds Association (MFHA), the governing body, published in October 2008 provides that hunt staff should be permitted to choose whether to wear a traditional hunt cap which does not comply with recognised safety standards or to wear a 'modern hat' which does comply with the required safety standards.
” 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 compliant protective headgear for public participants in hunting events
Wider context from the report “(1) Members of the public who participate in such- hunting events (i.e.'subscribers') are not required to wear protective head gear which complies with any relevant safety standards.
” Open source report
14 Sep 2015 ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 5 Insufficient supervision for immediate recognition of medical problems View source Lack of qualified first aiders View source Inadequate resuscitation attempts following collapse View source Lack of adequate risk assessment for gym users View source Absence of formalised national guidance on risk assessment in fitness centres and gyms 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
ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Stephen Cleveland collapsed after exercising unsupervised at a gym on 11 June 2013 and died some days later in intensive care following a cardiac arrest and hypoxic injury associated with severe coronary artery stenosis. Concerns included inadequate supervision and resuscitation, inadequate risk assessment, a lack of qualified first aiders, and the absence of formalised national guidance for risk assessment in fitness centres and gyms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Insufficient supervision for immediate recognition of medical problems
Wider context from the report “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately , and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that
there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms.
” 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 qualified first aiders
Wider context from the report “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders , and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that
there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms.
” 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 resuscitation attempts following collapse
Wider context from the report “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed . There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that
there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate risk assessment for gym users
Wider context from the report “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users , a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms. There was evidence that
there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms.
” 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 formalised national guidance on risk assessment in fitness centres and gyms
Wider context from the report “It is possible and entirely foreseeable that significant medical problems may arise in an environment where people are exercising and may have underlying medical problems that could predispose them to collapse. Given the severity of the underlying coronary artery disease and subsequent cardiac arrest here it is not possible to say in this particular situation whether this tragic outcome could have been avoided with an earlier and more effective response, but the evidence here was that there was not a level of supervision that enabled the problem to be recognised immediately, and neither was there an adequate attempt to resuscitate once it had been established that a person had collapsed. There was also evidence of absence of adequate risk assessment in respect of gym users, a lack of qualified first aiders, and an absence of formalised national guidance on risk assessment in fitness centres and gyms . There was evidence that
there was HSE guidance on swimming pool operations, but there is not for other facilities and it was felt that this would help the industry, particularly given the proliferation of such gymnasia in recent years, if there was formalised national guidance on risk assessment in fitness centres and gyms .
” Open source report
Concerns raised 1 Lack of guidance for effective cleaning of fixed shower heads 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
Margaret Elsie Clarke · 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
Margaret Elsie Clarke attended the Elements Spa in Rotherham on 14 March 2013 and later became ill, was admitted to Doncaster Royal Infirmary, and died on 27 March 2013. The inquest recorded myocardial infarction due to Legionella pneumonia, and the principal concern was the lack of guidance for effectively cleaning fixed shower heads used in leisure facilities.
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 guidance for effective cleaning of fixed shower heads
Wider context from the report “(1) There is no guidance for effective cleaning of fixed shower heads increasingly used in private and public leisure facilities.
” Open source report
10 Nov 2014 Myra Goldman · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Failure to distribute gate weight between hinges View source Failure to use a proprietary method to prevent gate removal by lifting at the hinges 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
Myra Goldman · 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
Myra Goldman died after a palisade gate fell on her. The Jury concluded that the gate fell because of fatigue of the lower right-hand hinged eye bolt and the configuration of the lugs and hinge pins; concerns were raised that this configuration placed most of the gate’s load on one hinge and that the relevant standard should be reviewed.
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 distribute gate weight between hinges
Wider context from the report “The inversion of the upper hinge pin is not an uncommon practice and is intended to prevent a gate from being easily lifted off its hinges. BS 1722-12:2006 specification for steel palisade fences which states that ‘hinges shall be designed so that it is impossible to remove the gates by lifting at the hinges when they are in the shut and locked position’. The standard gives examples of hinge arrangements and does not specifically preclude this method.
In the opinion of HM Specialist Inspector (Mechanical Engineering) of the Health & Safety Executive who gave evidence at the Inquest ‘the common sense approach is to spread the load’ between hinges by orientating them the same way rather than putting the significant majority of the weight of the gate onto one hinge only and ‘to prevent the gate from being easily lifted off, a proprietary method should be used such as double – lug hinge or anti-theft collars or split pins’. The preference of HM Specialist Inspector was for the standard to be ‘changed’.
Any change can only be considered / implemented at a review meeting of the British Standards Institute.
” 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 use a proprietary method to prevent gate removal by lifting at the hinges
Wider context from the report “The inversion of the upper hinge pin is not an uncommon practice and is intended to prevent a gate from being easily lifted off its hinges. BS 1722-12:2006 specification for steel palisade fences which states that ‘hinges shall be designed so that it is impossible to remove the gates by lifting at the hinges when they are in the shut and locked position’. The standard gives examples of hinge arrangements and does not specifically preclude this method.
In the opinion of HM Specialist Inspector (Mechanical Engineering) of the Health & Safety Executive who gave evidence at the Inquest ‘the common sense approach is to spread the load’ between hinges by orientating them the same way rather than putting the significant majority of the weight of the gate onto one hinge only and ‘to prevent the gate from being easily lifted off, a proprietary method should be used such as double – lug hinge or anti-theft collars or split pins’ . The preference of HM Specialist Inspector was for the standard to be ‘changed’.
Any change can only be considered / implemented at a review meeting of the British Standards Institute.
” Open source report
19 Jun 2014 Names not published · Prevention of Future Deaths report West Somerset
View report summary
Concerns raised 9 Failure to position lookouts for smoke or fog approaching nearby highways or railway lines View source Lack of immediate communication access to emergency services during firework displays View source Failure to assess humidity and wind conditions immediately before firework displays View source Lack of firework-firer training on recognising risks arising from high humidity View source Failure to prepare a comprehensive firework-display risk assessment View source Failure of road-safety-equipment deployment criteria to provide special consideration below six personal injury collisions in three years View source Lack of fog detection devices to identify reduced visibility before an initial incident View source Insufficient use of overhead gantries displaying reduced-visibility warnings View source Failure to ensure immediate stopping of firework displays when emergencies arise View source See 6 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
Names not published · 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
Seven people died when 34 vehicles collided in thick fog on the M5 motorway near Taunton on 4 November 2011; 51 others were injured. The concerns related to preventing vehicles entering areas of severely reduced visibility, detecting and warning of fog, and managing risks from firework displays that may increase fog or smoke near highways.
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 position lookouts for smoke or fog approaching nearby highways or railway lines
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity .
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 immediate communication access to emergency services during firework displays
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Failure to assess humidity and wind conditions immediately before firework displays
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display ,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 firework-firer training on recognising risks arising from high humidity
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose .
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 prepare a comprehensive firework-display risk assessment
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents .
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” 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 road-safety-equipment deployment criteria to provide special consideration below six personal injury collisions in three years
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility.
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration .
” 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 fog detection devices to identify reduced visibility before an initial incident
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility.
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration.
” 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 use of overhead gantries displaying reduced-visibility warnings
Wider context from the report ““A”
I am concerned that the Highway Agency's proposals whilst possibly preventing further vehicles entering an accident scene or a large area of reduced visibility would not prevent the initial incident and that this can only be achieved by the erection of fog detection devises and greater use of overhead gantries displaying signs warning of events that may cause reduced visibility .
AND as the criterion for deploying road safety equipment is six personal injury collisions in three years the present incident would not qualify for special consideration.
” 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 immediate stopping of firework displays when emergencies arise
Wider context from the report ““B”
To consider whether or not risks arising from firework displays being held in periods of very high humidity can be greatly reduced if the City and Guild’s courses for Firers and Senior Firers (being the only persons able to conduct a firework display using class IV fireworks) had instruction in realising when such risks arose.
AND before operating any display Firers had prepared :-
(i) a risk assessment which took account of the topography of the area, nearby watercourses, prevailing wind conditions, identifying highways and all other matters relevant for the safety of the users thereof onlookers and nearby residents.
(ii) Assessed the humidity, wind direction and speed immediately before the display,
(iii) Positioned lookouts to see if any smoke or fog was approaching a highway or railway line in the immediate vicinity.
(iv) Had immediate access to a communication link to the emergency services and
(v) Be able to stop the display immediately if an emergency arises
AND to consider whether Firers and Senior Firers should be licensed by law for periods of five year
AND whether Local Licensing Authorities shall advise persons holding firework displays of the risks referred to herein.
” Open source report
Concerns raised 2 Unsafe proximity of thumbwheel controls View source Lack of dual controls for locking-pin release 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
Elizabeth Joy Turnbull · 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
Elizabeth Joy Turnbull died on 15 June 2013 after being crushed by a bucket that dislodged from a telehandler while she was helping repair a stock fence. The concerns related to the layout of the thumbwheel controls, the absence of dual controls, and the ease with which the locking pins could be inadvertently released.
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 Unsafe proximity of thumbwheel controls
Wider context from the report “(1) The layout of the thumbwheel controls namely one immediately above the other , the first controlling release of locking pins which secure buckets and attachments, and the second thumbwheel used to move the telescopic arm backwards and forwards .
(2) The absence of any dual controls which would both have to be activated before the pins could be released.
(3) Due to 1 and 2 above the ease at which the user could inadvertently release locking pins rather than moving the telescopic arm
” 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 dual controls for locking-pin release
Wider context from the report “(1) The layout of the thumbwheel controls namely one immediately above the other, the first controlling release of locking pins which secure buckets and attachments, and the second thumbwheel used to move the telescopic arm backwards and forwards.
(2) The absence of any dual controls which would both have to be activated before the pins could be released .
(3) Due to 1 and 2 above the ease at which the user could inadvertently release locking pins rather than moving the telescopic arm
” Open source report
Concerns raised 2 Absence of direct or indirect managerial supervision of volunteer activities View source Lack of appropriate risk assessments for volunteer activities around the museum site 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
Karl Doran · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Karl Doran, a seven-year-old boy volunteering with his father at Beamish Museum, fell from or near a steam roller and was almost immediately crushed by a heavy steel-wheeled trailer. The concern was that Beamish had not carried out appropriate risk assessments or provided direct or indirect managerial supervision for the volunteers’ activities.
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 Absence of direct or indirect managerial supervision of volunteer activities
Wider context from the report “(1) Beamish had not carried out a appropriate risk assessments to ensure the safety of volunteers such as Karl and his father when engaging in activities around the museum site. There was no direct or indirect managerial supervision of these volunteers activities .
” 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 appropriate risk assessments for volunteer activities around the museum site
Wider context from the report “(1) Beamish had not carried out a appropriate risk assessments to ensure the safety of volunteers such as Karl and his father when engaging in activities around the museum site . There was no direct or indirect managerial supervision of these volunteers activities.
” Open source report
22 Nov 2013 Garrett Joseph Franklin ELSEY · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Failure to ensure industry awareness of guidance on people in commercial waste containers 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
Garrett Joseph Franklin ELSEY · 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
Garrett Joseph Franklin ELSEY, aged 22, was found among waste dumped at a refuse site after collection by a refuse lorry. The concern was that an important HSE document about people in commercial waste containers might not have been read by the public, and that an alert system might be needed to raise awareness in the industry.
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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 Failure to ensure industry awareness of guidance on people in commercial waste containers
Wider context from the report “A HSE document entitled “People in Commercial Waste Containers”, “Waste 25”, was produced at the inquest as evidence. It is of concern that this important document may not have been read by the public so possibly some sort of alert system could be set up to ensure that everybody in this industry is aware of this document .
” Open source report
18 Oct 2013 ELIZABETH AURORA KERR · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 14 Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances View source Absence of a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement View source Lack of suitable training in the operation of carbon monoxide detection equipment View source Lack of clear oversight of gas-supplier steps to raise awareness of danger View source Lack of clear gas-supplier criteria for identifying vulnerable and priority customers View source Failure to identify incomplete flue piping during routine inspections View source Lack of understanding and detailed guidance on the movement of carbon monoxide within buildings View source Lack of established monitoring of offers and uptake of free annual gas safety checks View source Lack of a duty to warn other occupants to install carbon monoxide alarms View source Lack of regulatory coverage for ongoing maintenance and inspection of existing solid fuel appliances View source Lack of a duty to allow recognised engineers to inspect boilers in multi-occupancy buildings View source Lack of required audit trails of fuel-supplier carbon monoxide safety steps View source Lack of HSE guidance to landlords and letting agents on independent validation of gas and other fuel safety equipment in rented property View source Lack of required specific carbon monoxide safety information from fuel suppliers View source See 11 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
ELIZABETH AURORA KERR · 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
Elizabeth Aurora Kerr died after carbon monoxide from a malfunctioning basement boiler entered the residential flat where she lived, and she was found unconscious several hours after the Fire Service had attended the building. The report identified concerns about the movement and detection of carbon monoxide in buildings, the absence and use of carbon monoxide alarms and gas safety controls, and Fire and Rescue Service equipment, guidance and responses.
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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 Unavailability of carbon monoxide detection equipment on Fire and Rescue Service frontline appliances
Wider context from the report “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms.
GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public.
” 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 a statutory Fire and Rescue Service role in carbon monoxide safety, regulation and enforcement
Wider context from the report “3. The Role of Fire and Rescue Services in Carbon Monoxide Safety:
The Fire and Rescue Services currently have no statutory role in Carbon Monoxide safety, regulation and enforcement. This could be reviewed and considered by the Department for Communities and Local Government. It is appreciated that this is far from straight forward and wider issues would need to be taken into account. For example Fire and Rescue Services have no statutory role in other gases or substances which can cause death. This may require a more detailed analysis and assessment of issues and complications which may then come to light. In the absence of a statutory role, and possibly through the Chief Fire Officers Association “Blue Watch” initiative, Fire and Rescue Services could be encouraged to voluntarily engage in local and national Carbon Monoxide campaigns. Such campaigns may benefit from closer working at a local level with relevant CO charities and at a national level between the Gas Safety Trust, the Gas Safe Charity and the Chief Fire Officers Association.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable training in the operation of carbon monoxide detection equipment
Wider context from the report “7. The use and availability of CGI meters by Fire and Rescue Services and having suitable training in their operation as well as the use of personal protective equipment CO alarms.
GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public.
” 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 oversight of gas-supplier steps to raise awareness of danger
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 gas-supplier criteria for identifying vulnerable and priority customers
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 incomplete flue piping during routine inspections
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and detailed guidance on the movement of carbon monoxide within buildings
Wider context from the report “2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services.
” 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 established monitoring of offers and uptake of free annual gas safety checks
Wider context from the report “4. Piped Gas Suppliers:
It is understood that there are specific conditions of a licence to supply gas as summarised below. It is not clear how gas suppliers define and determine who is a ”vulnerable and priority” customer and how it is established that they have been offered a free annual gas safety check, and have taken advantage (or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps?
” 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 duty to warn other occupants to install carbon monoxide alarms
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Health and Safety Executive; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory coverage for ongoing maintenance and inspection of existing solid fuel appliances
Wider context from the report “6. The installation , use , maintenance and correct positioning of fixed hard wired or battery operated CO alarms.
From October 1st 2010 Building Regulations Approved Document J “Combustion appliances and fuel storage systems” sets out a number of legal requirements in England and Wales. For the first time carbon monoxide (CO) alarms were made mandatory “where a new or replacement fixed solid fuel appliance is installed in a dwelling, a CO alarm should be provided in the room where the appliance is located.” However Building Regulations only concern the processes used during the ‘building’ or ‘installation’ phases, of a solid fuel appliance and do not have any power to talk about on-going maintenance processes or the inspection of existing appliances.
” 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 duty to allow recognised engineers to inspect boilers in multi-occupancy buildings
Wider context from the report “8. The Chief Fire Officers Association “Blue Watch Initiative”
This is a voluntary initiative to be encouraged and supported. It offers an independent safety validation service for landlords and letting agents.
http://www.bluewatch.co.uk/. The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by The Gas Safety (Installation and Use ) Regulations 1988. At present there is no duty imposed on the owner of a boiler or a gas supplier ( who makes a profit from the supply ) that in the case of a multi occupancy building to allow the other occupants , through recognised engineers , to inspect the boiler and be warned to install CO alarms.
” 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 required audit trails of fuel-supplier carbon monoxide safety steps
Wider context from the report “5. Enforcement and Information:
There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give.
” 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 to landlords and letting agents on independent validation of gas and other fuel safety equipment in rented property
Wider context from the report “2. Guidance on the potential movement of CO within a building:
There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more information on its web site and provide specific guidance or warnings. There is no HSE guidance to landlords and letting agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services.
” 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 required specific carbon monoxide safety information from fuel suppliers
Wider context from the report “5. Enforcement and Information:
There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of fitting an audible alarm. At the moment there is no specific information that fuel suppliers are required to give.
” Open source report
Concerns raised 3 Failure of regular external inspections to recognize relevant physical safety matters View source Failure to cover or otherwise maintain safe temperatures for exposed heating pipes and valves View source Lack of risk assessment of room-specific physical safety for individual residents 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
Walter Gordon Powley · 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
Walter Gordon Powley died after falling against uncovered radiator pipes and valves at a care and nursing home, sustaining burns to his legs. The report raised concerns about the high temperature of uncovered pipework, the absence of risk assessment of the room’s physical circumstances, and inspection bodies not identifying these issues. The inquest also identified inadequate ongoing risk assessments and failures to adhere to procedures for giving and recording medication as contributing factors.
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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 Failure of regular external inspections to recognize relevant physical safety matters
Wider context from the report “3.Western Park View had been inspected by the Care Quality Commission and the Local Authority on a regular basis. Evidence indicated that these matters referred to had not been recognized by those bodies.
” 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 cover or otherwise maintain safe temperatures for exposed heating pipes and valves
Wider context from the report “1.Neither the pipes that he fell against nor the valves that connected those pipes to the radiator, were covered. HSE published guidance indicated that the maximum temperature of such pipes should be 43 degrees centigrade . Readings taken from uncovered pipes both in Mr Powley’s room and other rooms in the Home indicated that the temperatures ranged between 60 degrees centigrade and more than 70 degrees centigrade . Evidence was given at the Inquest that a number of other residential homes in this area did not have pipes and valves covered. It may well be therefore that this applies throughout 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 Lack of risk assessment of room-specific physical safety for individual residents
Wider context from the report “2.It was therefore also apparent that there had not been a risk assessment of the physical circumstances in that room, and whether it was therefore safe for a particular resident .
” 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 the concerns and response with local-authority health and safety regulators through the Local Authority Unit.
Verbatim wording from the response “HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.” Source location 2013-0251-Response-by-Health-Safety-Executive
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Map relevant social-care safety standards and explore how they can best be promulgated through an established task-and-finish group.
Verbatim wording from the response “HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators, care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance and disseminating it to the sector. HSE sees this as appropriate forum to raise your concerns and it is our intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting. It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards.” Source location 2013-0251-Response-by-Health-Safety-Executive
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the risks from hot surfaces and pipework at the next Social Care Partners Forum meeting.
Verbatim wording from the response “HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators, care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance and disseminating it to the sector. HSE sees this as appropriate forum to raise your concerns and it is our intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting. It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards.” Source location 2013-0251-Response-by-Health-Safety-Executive
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the Health and Safety Executive’s care-home safety booklet, HSG220.
Verbatim wording from the response “HSE has guidance on the risks from hot water and surfaces on its Health and Social Care web pages (http://www.hse.gov.uk/healthservices/scalding-burning.htm), including Information Sheet 6. Further information can also be found in HSE booklet ‘Health and safety in care homes’ (HSG220) which is available on the website and is currently being reviewed and updated. It is hoped that the revised version will be available in early Spring 2014.” Source location 2013-0251-Response-by-Health-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 Local authorities enforce health and safety in non-nursing residential care, including relevant standards and compliance concerns.
Verbatim wording from the response “HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.” Source location 2013-0251-Response-by-Health-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 CQC is the lead regulator and inspection body better placed to proactively lead on health and social care service-user safety.
Verbatim wording from the response “I totally understand your concerns but see CQC as the lead regulator and inspection body in England for health and social care providers and we believe they are better placed to proactively lead on service user safety issues. I note that you have also written to CQC.” Source location 2013-0251-Response-by-Health-Safety-Executive
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations