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Investigation and inquest
On 30 October 2020 I commenced an investigation into the death of Zachariah Nathaniel RICHARDSON aged 18. The investigation concluded at the end of the inquest on 23 September 2022.
The medical cause of death was:
1a) Compression Asphyxia
1b)
1c)
2)
The conclusion of the inquest was:
Accidental Death.
Circumstances of the death
Mr Richardson started working for Lincs Firewood on 6 October 2020. He completed a two day practical and theoretical training course on operating forklift trucks (FLTs) on 18 October 2020. On 24 October 2020 Mr Richardson went to DD Dodds and Son’s Elm Farm Site to help tidy up the site. He was alone approximately 15.51 hours until 17.13 hours. At approximately 17.16 hours Mr Richardson was found trapped between a FLT and a wall. Mr Richardson suffered fatal injuries and was declared dead at the scene.
Coroner’s concerns
1. Evidence was heard at the inquest that Mr Richardson, aged 18 years, had joined Lincs Firewood some 18 days prior to his death and had undergone training to use a FLT some 6 days prior to his death. He was left alone on a site for approximately 1 hour 20 minutes, which he had visited on one occasion a few days prior to his death.
2. The evidence was that the FLTs at the Elm Farm site were seven months overdue for the annual Thorough Examination and had undergone a service since February 2019. The seat safety switch device on the FLTs had been defeated at some point prior to the incident. The seat safety switch device on one of the FLTs was defective
3. Evidence was heard at the inquest that a Health and Safety Consultant visited the sites at Lincs Firewood and Dodds and Son in October and November 2020, following Mr Richardson’s death. The Consultant found there was little understanding of the importance of health and safety because there were no systems in place although working on high risk machinery. The perception of risk was found to be “poor” and “no one had taken the time or understood the importance to become competent in health and safety prior to the incident”
4. As at the time of making the Report in September 2021, no feedback had been received disagreeing with or challenging any of the findings in the Report
5. An email dated 11 November 2020 from Boston District Council to Health and Safety Executive referred to a visit made to the site that day which found “Refusal to accept the nature of the goods in the yard presents a leptospirosis risk but agreed to issue pocket cards!” and “Some doubt as to the interpretation of the LOLER regs” [which applied to the use and operation of the machinery on site].
6. As at the date of the inquest, some 23 months following Mr Richardson’s death, no evidence was heard as to any changes which had been made with regard to health and safety at either Lincs Firewood or DD Dodds and Son
Information checked against the published report and official responses