PFD report

ARTHUR CAXTON MASON · Prevention of Future Deaths report

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Issued 1 Apr 2016•Norfolk

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.

View original report
Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
14

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 raised6

  1. Failure to apply Health & Safety Executive risk-assessment guidance
  2. Failure to ensure a risk assessment is in place for the new cleaning procedure
    Part of recurring concern: Failure to assess risks before introducing new work procedures
  3. Failure to identify risks in farm task risk assessments
    Part of recurring concern: Failure to assess risks before hazardous work tasks
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.7

  1. Action

    Complete the booked IOSH Directing Safely, IOSH Managing Safely and first-aid training for designated managers.

    Stated by Maurice Mason LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 April 2016.
  2. Action

    Provide further focused safety training for staff with CSML’s advice and input.

    Stated by Maurice Mason LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 April 2016.
  3. Action

    Provide access to CSML’s updated health-and-safety documentation, legislation updates and telephone support.

    Stated by Maurice Mason LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 April 2016.

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

  1. Position

    The company states that prohibiting personnel from entering grain bins has eradicated the confined-space risks identified in the concern.

    Stated by Maurice Mason LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 apply Health & Safety Executive risk-assessment guidance

Wider context from the report

“(1) As at July 2014 no member of staff had undergone training in respect of assessing risks and carrying out Risk Assessments. Following Mr Mason's death, one member of staff involved in risk assessments has undergone training. This member of staff is involved in the administration side of documents. Other, senior, members of staff involved in carrying out risk assessments have not undergone any such training and from the evidence did not appear to fully accept risks as set out in Health & Safety Executive documentation, preferring to rely on their own “experience and common sense”. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 a risk assessment is in place for the new cleaning procedure

Wider context from the report

“(2) It was unclear from the evidence that staff involved in carrying out Risk Assessments recognised the risks of carrying out various tasks on the farm. The current document "Procedure for Cleaning out Grain Bins" does not recognise any risks or hazards in carrying out the tasks and it was not clear from the evidence a Risk Assessment is in place for this new procedure, introduced following and as a result of Mr Mason’s death. ”

Is this part of a recurring concern?

Yes — Failure to assess risks before introducing new work procedures.

Open source report

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 identify risks in farm task risk assessments

Wider context from the report

“(2) It was unclear from the evidence that staff involved in carrying out Risk Assessments recognised the risks of carrying out various tasks on the farm. The current document "Procedure for Cleaning out Grain Bins" does not recognise any risks or hazards in carrying out the tasks and it was not clear from the evidence a Risk Assessment is in place for this new procedure, introduced following and as a result of Mr Mason’s death. ”

Is this part of a recurring concern?

Yes — Failure to assess risks before hazardous work tasks.

Open source report

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

Lack of training for staff carrying out risk assessments

Wider context from the report

“(1) As at July 2014 no member of staff had undergone training in respect of assessing risks and carrying out Risk Assessments. Following Mr Mason's death, one member of staff involved in risk assessments has undergone training. This member of staff is involved in the administration side of documents. Other, senior, members of staff involved in carrying out risk assessments have not undergone any such training and from the evidence did not appear to fully accept risks as set out in Health & Safety Executive documentation, preferring to rely on their own “experience and common sense”. ”

Is this part of a recurring concern?

Yes — Inadequate competence of personnel conducting formal safety risk assessments.

Open source report

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

Absence of an emergency plan or procedure for employees

Wider context from the report

“(3) The “what to do in an emergency” Sheet in place as at July 2014 contained a list of persons to contact and telephone numbers and coordinates to pass to emergency services. There was no Emergency Plan in place. This has not changed following Mr Mason's death. Although the grain bins are not to be entered by any personnel on cleaning, it was clear from the evidence, there are other hazardous areas on the farm. These “Emergency Sheets” are currently in use and there is no plan or procedure in place for employees to follow should another emergency occur. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Cleaning-out-grain-bins procedure failing to identify risks and hazards

Wider context from the report

“(2) It was unclear from the evidence that staff involved in carrying out Risk Assessments recognised the risks of carrying out various tasks on the farm. The current document "Procedure for Cleaning out Grain Bins" does not recognise any risks or hazards in carrying out the tasks and it was not clear from the evidence a Risk Assessment is in place for this new procedure, introduced following and as a result of Mr Mason’s death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 the booked IOSH Directing Safely, IOSH Managing Safely and first-aid training for designated managers.

Verbatim wording from the response

“To broaden MML’s understanding of Health and Safety and to strengthen our ability to ensure that staff who are responsible for health and safety understand the issues and risks involved, further formal training has been booked as set out below. In particular:-”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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 further focused safety training for staff with CSML’s advice and input.

Verbatim wording from the response

“There will be further training for staff members in more focused areas to strengthen staff involvement and understanding. It is not possible at this time to give details but it will be on the advice and with input from CSML.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 3 · response
Published 1 April 2016

Open published response

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 access to CSML’s updated health-and-safety documentation, legislation updates and telephone support.

Verbatim wording from the response

“g) Internet access to CSML updated H+S documentation, to keep MML updated with current legislation along with telephone contact/support.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Commission CSML to review and amend health-and-safety policies, risk assessments, safe systems, emergency plans and the employee handbook.

Verbatim wording from the response

“In order to address the Coroner’s concerns and to address safety issues across MML, the Company has instructed Cope Safety Management Ltd (CSML) (qualifications attached) to review and amend:-”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Prohibit personnel from entering grain bins for cleaning or any other purpose.

Verbatim wording from the response

“MML has taken the actions set out below in order to comply with the Coroner’s Report and in order to further review health and safety across its business, not just in respect of the areas highlighted by the Coroner’s Report. In relation to practices on the farm concerning the cleaning of grain bins it is now the case that no personnel whatsoever are to enter the grain bins at any time for cleaning, or indeed any other purposes. This practice no longer forms part of any work at MML. Therefore the potential risks in relation to working inside the grain bins have been eradicated. As a result there is no remaining risk on site of working in a confined space – such that was the subject of evidence at the inquest.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 1 · response
Published 1 April 2016

Open published response

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 and update the grain-store risk assessment and method statement for the revised cleaning method.

Verbatim wording from the response

“With regards to the specific grain store building, a new risk assessment has been done along with a method statement. It is now more detailed and addresses the risks of the new method of work. A copy is attached. This now addresses the risks that are present in the new cleaning method and the appropriate method of work for cleaning the bins. This document was updated as a result of a visit from the HSE, after the Inquest. A version of this updated document will also be sent independently to the HSE and it will also be subject to further review by Cope Safety Management Ltd (see below).”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Have CSML review emergency plans and prepare appropriate plans addressing the Coroner’s concerns.

Verbatim wording from the response

“As referred to above emergency plans will be specifically reviewed by CSML and prepared as and where appropriate on the advice of CSML and to address the concerns of the Coroner in relation to Emergency plans. At the time of the accident there were two fully trained and current, first aiders on site. These were ████████. There has been a fully maintained defibrillator on farm since 30th Jan ’15, with open access. All MML staff have been fully trained in its use along with first-aid training.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 3 · response
Published 1 April 2016

Open published response

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 company states that prohibiting personnel from entering grain bins has eradicated the confined-space risks identified in the concern.

Verbatim wording from the response

“MML has taken the actions set out below in order to comply with the Coroner’s Report and in order to further review health and safety across its business, not just in respect of the areas highlighted by the Coroner’s Report. In relation to practices on the farm concerning the cleaning of grain bins it is now the case that no personnel whatsoever are to enter the grain bins at any time for cleaning, or indeed any other purposes. This practice no longer forms part of any work at MML. Therefore the potential risks in relation to working inside the grain bins have been eradicated. As a result there is no remaining risk on site of working in a confined space – such that was the subject of evidence at the inquest.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 1 · response
Published 1 April 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Continue working with CSML and, where necessary, the HSE to maintain high standards of site safety practice.

    Stated by Maurice Mason LimitedStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2016.
  2. 2

    Complete the factory manager’s IOSH Managing Safely course.

    Stated by Maurice Mason LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
  3. 3

    Maintain an accessible defibrillator and ensure staff receive defibrillator-use and first-aid training.

    Stated by Maurice Mason LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
  4. 4

    Provide quarterly health-and-safety updates.

    Stated by Maurice Mason LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 April 2016.
  5. 5

    Appoint CSML as MML’s nominated safety adviser under a two-year contract.

    Stated by Maurice Mason LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
  6. 6

    Arrange four annual site safety inspections through CSML.

    Stated by Maurice Mason LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 April 2016.
  7. 7

    Deliver on-site toolbox talks with staff and appropriate safety literature.

    Stated by Maurice Mason LimitedStated plannedThe respondent said that this action was planned when they made their response on 1 April 2016.

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

Continue working with CSML and, where necessary, the HSE to maintain high standards of site safety practice.

Verbatim wording from the response

“MML believes that it has responded to the Coroner’s report actively and positively but it will continue to work both with CSML and the HSE, where necessary, to ensure high standards of practice are adopted across its site.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 3 · response
Published 1 April 2016

Open published response

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 the factory manager’s IOSH Managing Safely course.

Verbatim wording from the response

“████████ (office manager)”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Maintain an accessible defibrillator and ensure staff receive defibrillator-use and first-aid training.

Verbatim wording from the response

“As referred to above emergency plans will be specifically reviewed by CSML and prepared as and where appropriate on the advice of CSML and to address the concerns of the Coroner in relation to Emergency plans. At the time of the accident there were two fully trained and current, first aiders on site. These were ████████. There has been a fully maintained defibrillator on farm since 30th Jan ’15, with open access. All MML staff have been fully trained in its use along with first-aid training.”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 3 · response
Published 1 April 2016

Open published response

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 quarterly health-and-safety updates.

Verbatim wording from the response

“h) Quarterly updates on H+S matters”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Appoint CSML as MML’s nominated safety adviser under a two-year contract.

Verbatim wording from the response

“CSML becomes MML’s nominated safety advisor. This is a two year contract, formal signing was 28th April ’16 (copy of agreement enclosed, please note that it is Option 1 that is being taken).”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Arrange four annual site safety inspections through CSML.

Verbatim wording from the response

“e) Site safety inspections (4 per year)”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response

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

Deliver on-site toolbox talks with staff and appropriate safety literature.

Verbatim wording from the response

“f) “Tool Box” talks held on site with staff, complete with appropriate literature”

Source location

2016-0128-Response-by-Maurice-Mason-Ltd
Page 2 · response
Published 1 April 2016

Open published response
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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