14 Dec 2015 Paul David Whitehead · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 4 Failure of First Aid provision to maintain effective resuscitation capability View source Failure of emergency-site access and wayfinding to expedite Ambulance arrival View source Lack of immediately available First Aid provision View source Delays in calling an Ambulance after an incident View source See 1 more concern
Responses linked to these concerns
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Paul David Whitehead · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.
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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 W.E.Rawson Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of First Aid provision to maintain effective resuscitation capability
Wider context from the report “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty.
(2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager.
(3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation .
(4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes.
These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur.
Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty.
” 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 W.E.Rawson Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency-site access and wayfinding to expedite Ambulance arrival
Wider context from the report “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty.
(2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager.
(3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation.
(4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door . The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes .
These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur.
Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty.
” 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 W.E.Rawson Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of immediately available First Aid provision
Wider context from the report “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty .
(2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager.
(3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation.
(4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes.
These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur.
Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty.
” 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 W.E.Rawson Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an Ambulance after an incident
Wider context from the report “(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty.
(2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance . The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager.
(3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation.
(4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes.
These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur.
Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty.
” 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 Refresh all first aiders’ first-aid training regularly in line with HSE guidance.
Verbatim wording from the response “We will prepare all of our first aiders so far as possible by refreshing their first aid training on a regular basis in line with HSE guidance. The First Aider in question has already been provided with refresher training following the incident.” Source location Paul-Whitehead-Response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide flashlights in the security cabin for lookouts to attract emergency services’ attention.
Verbatim wording from the response “The revised Emergency procedures document now clearly states that the “lookouts” must be stationed at all of the access points to the site. Additionally we are ensuring that flash lights are kept in the security cabin which the lookouts are required to use as an aid for attracting the attention of the emergency services.” Source location Paul-Whitehead-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 Complete a full review and compile a controlled Emergency Procedures document addressing the reported safety concerns.
Verbatim wording from the response “Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;” Source location Paul-Whitehead-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 the new Emergency Procedures document to all personnel as a refresher, including instructions to call emergency services promptly and station lookouts at site access points.
Verbatim wording from the response “Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters raised in the Regulation 28 Report to prevent future deaths, I have the following information;” Source location Paul-Whitehead-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 Introduce appointed persons across factory departments and train production charge hands in basic first aid and initial emergency response.
Verbatim wording from the response “It is proposed to introduce a number of ‘Appointed Persons’ within the factory departments. Production Charge Hands across the manufacturing facility will be trained in basic first aid skills and will be able to provide initial and first response aid to a person in the event of an accident or injury in the immediate vicinity. The existing first aiders (First Aid at Work qualification) would then take over once arriving at the scene of an incident. We would expect this to enable a more immediate response in the event of a future incident. We are targeting this to be implemented and training provided as suggested above by 31 March 2016.” Source location Paul-Whitehead-Response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is difficult to prepare non-medical first aiders to avoid freezing from shock during incidents as severe as this one.
Verbatim wording from the response “3) The First Aider was unable to perform mouth to mouth resuscitation.” Source location Paul-Whitehead-Response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The first aider correctly prioritised the emergency-services call before contacting the company Health and Safety manager.
Verbatim wording from the response “2) Mixed evidence about whether the designated first aider prioritised actions correctly and called the Ambulance or the company Health & Safety manager first.” Source location Paul-Whitehead-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations