Recipient

Recipient name withheld

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First report 20 Nov 2018•Latest report 20 Nov 2018

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. North Wales (East and Central)

    AI-generated summary

    Austin Allen Ellsum THOMAS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Austin Allen Ellsum THOMAS died after being struck by a Volvo shovel loader truck while walking on the factory floor at a paper mill on 6 February 2017. The concerns identified were the potential distraction caused by music played at high volume in heavy machinery and the absence of random drug testing for employees operating heavy machinery, particularly drivers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to control high-volume music use while operating heavy machinery

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of policy governing music and CD use while operating machinery

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review or update the drugs policy

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to eliminate simultaneous pedestrian and vehicle movement on the factory floor

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of random drug testing for drivers operating heavy machinery

    Wider context from the report

    “(1) I heard evidence from an expert vehicle examiner who upon examination of the volvo shovel loader truck involved in the fatal accident found a CD in the CD compartment within the drivers cab of the truck. This CD player allowed CD’s to be played to a volume level of 32. I heard no evidence as to when the CD was last listened to however, I am concerned that there exists an inbuilt facility for drivers to listen to music at high levels when operating heavy machinery in a confined space such as the warehouse. Whilst I heard evidence that a new radio communication system would cut out any music playing in the truck cab I am concerned that the levels of volume are such that they could provide a distraction for a driver. I also heard evidence that whilst instances of pedestrians and vehicles moving on the factory floor at the same time had been significantly reduced, it had not been eliminated altogether. The combination of a driver being distracted listening to music in a contained environment where heavy machinery is being operated presents a risk of future deaths. Whilst neither the existence of the CD player nor the playing of any CD was involved in this inquest, having raised the concern at the end of the inquest, no policy or working rules or regulations relating to the listening of music and or CD’s whilst operating machinery for employees at the paper mill factory or any factory owned and operated by Downtons or UPM was brought to my attention. I make it clear that this issue played no part in the inquest of the deceased. (2) The inquest heard evidence as to the levels of cannabis in the blood of the driver of the shovel loader truck some 7 hours after the fatal incident. No evidence was available as to the levels of cannabis in the drivers system at the time of the fatal incident. The inquest heard evidence from the driver himself as to his cannabis use which included an admission that he had smoked cannabis on his own evidence the night before commencing an early shift the following day. The inquest also heard evidence that the drivers admitted use of cannabis was not consistent with the levels detected in his blood. I have been provided with a drugs policy from the factory operator which provides for drug testing on a ‘show cause’ basis only. There is no policy in relation to random testing particularly for drivers operating heavy machinery. Given the evidence heard at the inquest I am concerned that an employee may use drugs without the knowledge of his employer and continue to operate heavy machinery creating a risk of future deaths. I note that the policy I have been provided with does not appear to have been reviewed or updated following the incident resulting in the death of Mr Thomas in February 2017. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026