Christopher BEVAN · Prevention of Future Deaths report

On 06/09/2018 I commenced an investigation into the death of Christopher BEVAN. The investigation concluded at the end of the inquest held on 12ᵗʰ-14ᵗʰ March 2019. The conclusion of the inquest was that the Deceased died as a consequence of an accident and that the medical cause of death was:

1(a) Diffuse brain swelling (operated)

1(b) Blunt head trauma with skull fractures

The circumstances of the death, as determined by the jury, were that on 14ᵗʰ August 2018 between 1500hrs and 1540hrs at ████████ the Deceased was last seen undertaking work to the garage roof whilst on a ladder and that he fell and sustained head injuries. The date of death was 15ᵗʰ August 2018 at 1900hrs at Royal Preston Hospital. The jury’s conclusion as to death was “Accident”.

(1) That ladders may be used in the course of your work (a) in circumstances in which their use may present a risk to life and/or (b) in a manner in which their use may present a risk to life. The Court received evidence to the effect that the ladders in use at the time of the fatal accident on 14ᵗʰ August 2018 were used on a surface which may have been slippery, that they were not footed during use, that they were not secured at the top save to the extent that they were supported by the blockwork and/or by recently laid coping stones of a facing wall above the door opening of the garage and that they may have been used by the Deceased, with whom you had been working, in a manner which involved him assuming an awkward position in order to carry out your work. The concern therefore arises that you may use or those with whom you may work may use ladders in circumstances or in a manner which present a risk to you, to them and/or to others.