Investigation and inquest
On 10 December 2020 I commenced an investigation into the death of Tony WILLIAMS aged 45. The investigation concluded at the end of the inquest on 15 July 2024. The conclusion of the inquest was that the death was a Misadventure.
Circumstances of the death
On 2 December 2020, Tony Williams, an HGV driver for ████████, was delivering bales of hay to ████████ in Cheshire. Thirty-three hay bales were loaded onto the 45ft HGV at ████████ in Suffolk by the farm director in the presence of Mr Williams, who was experienced in the strapping and loading of Hesston bales. Three bales were loaded with the bale widthways, the opposite direction to the rest of the bales, on the back end of the vehicle.
On the journey from Suffolk, somewhere along the route an ANPR camera had caught an image of hay overhanging the back of the vehicle. When arriving at ████████ with the assistance of a banksman, Mr Williams reversed down ████████ a public domain road with a known slope comparable to a wheelchair ramp. Mr Williams was witnessed by a Farmhand unstrapping the load when the three width ways bales fell from the back. Two of which fell on top of Mr Williams.
The Farmhand who witnessed the unstrapping, removed the bales from Mr Williams with his telehandler and administered CPR with guidance from the ambulance service operator. When the ambulance arrived advanced life saving measures were administered to no avail. He was pronounced dead at the scene at 11:01 hours.
Coroner’s concerns
The configurations for safely loading bales widthways, on a slope of 4.5 degrees and utilising crisscross strapping were considered in evidence. HSE produced laser measurements and images identifying the centre of gravity and risks associated with unloading overhanging bales on a slope when the most rearward bales are loaded widthways. HSE concluded that the accident would not have occurred if Mr Williams had not unloaded with the overhang facing downhill.
It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales.