PFD report

Sean Patrick O’CONNOR · Prevention of Future Deaths report

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Issued 8 May 2024•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to ensure required daytime checks on lone workers
    Part of recurring concern: Unreliable safety arrangements for lone workers
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Update the Contractor Handbook and Lone Working Policy to apply to contractors.

    Stated by Canary Wharf Management LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
  2. Action

    Trial a welfare-check process for lone workers applying for work authorisation, including prompts, competent-person checks, and system recording.

    Stated by Canary Wharf Management LimitedStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
  3. Action

    Review the six-month trial, assess its effectiveness, and decide whether further changes are needed.

    Stated by Canary Wharf Management LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The existing risk-based system and checks are considered adequate, and broader checks could divert resources from higher-risk work.

    Stated by Canary Wharf Management LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure required daytime checks on lone workers

Wider context from the report

“I heard evidence at inquest that, as he was regarded as a lone worker, Sean O’Connor could and, according to the risk assessment method statement (RAMS), should have asked a CWML colleague to come to check on him during the day. He did not ask for such a check and, although a CWML employee thought of doing so, that person was busy and so did not. Whilst such a check is likely to have taken place too late in the day to have changed the outcome for Mr O’Connor, that might be different for another lone worker. Several witnesses gave evidence that discussions take place with every worker coming on site as a matter of routine, covering such matters as where the worker is meant to be located, the exact nature of the job and so forth. The CWML director who gave evidence at inquest agreed with me that it would be a straight forward matter to include within that as a point always for brief discussion, whether any checks are required during the day. In this way, if the operative forgets to ask, the discussion can act as a reminder. ”

Is this part of a recurring concern?

Yes — Unreliable safety arrangements for lone workers.

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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

Update the Contractor Handbook and Lone Working Policy to apply to contractors.

Verbatim wording from the response

“In addition to the above, CWML will be updating the Contractor Handbook and the Lone Working Policy to apply to contractors.”

Source location

Response from Canary Wharf Management
Page 2 · response
Published 14 May 2024

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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

Trial a welfare-check process for lone workers applying for work authorisation, including prompts, competent-person checks, and system recording.

Verbatim wording from the response

“Notwithstanding the above, and as part of a process of continuous improvement, CWML has decided to trial a new feature to apply to WA, beginning July 2024. The arrangements will include:”

Source location

Response from Canary Wharf Management
Page 1 · response
Published 14 May 2024

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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 the six-month trial, assess its effectiveness, and decide whether further changes are needed.

Verbatim wording from the response

“These arrangements will apply in addition to the independent contractors' procedures for lone working. The trial is intended to run for 6 months at the end of which CWML will review the results, consider their effectiveness and decide whether to implement some or all of the trial or make any further changes.”

Source location

Response from Canary Wharf Management
Page 2 · response
Published 14 May 2024

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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 existing risk-based system and checks are considered adequate, and broader checks could divert resources from higher-risk work.

Verbatim wording from the response

“CWML’s approach to facilitating access to its premises by independent contractors reflects what it understands to be recognised practice. CWML is not aware of any concerns raised by contractors (including Mitsubishi) before the incident involving Mr O'Connor. The existing CWML system prioritises checks based on risk (higher risk works requiring a PtW involve mandatory checks and are rarely performed by lone workers). CWML is mindful of the need to avoid potentially undermining the strengths of the system by diverting resource away from higher risk works.”

Source location

Response from Canary Wharf Management
Page 1 · response
Published 14 May 2024

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

Data last updated 7 September 2026