Paul David Whitehead · Prevention of Future Deaths report

On 3 April 2014 I commenced an investigation into the death of Paul David Whitehead, Age 49. The investigation concluded at the end of the Inquest on 11 December 2015. The conclusion of the inquest was a Narrative Conclusion that Paul David Whitehead sustained serious injuries on Friday 28 February 2014 when working on a Desco packing machine in the course of his employment at W E Rawson Ltd, Castle Bank Mills, Portobello Road, Wakefield and subsequently died on Sunday 2 March 2014 at Leeds General Infirmary as a result of the multiple injuries sustained.

Paul David Whitehead was a Charge Hand operating a Desco packing machine in the Bottom Mill in the course of his employment with W E Rawson Ltd on a night shift commencing around 6pm on Friday 28 February 2014. He was discovered trapped between the lower and upper moving conveyors of the machine having sustained severe crush injuries, from which he subsequently died.

(1) When Mr Whitehead was released from the machine and fell on to the floor, a witness said that there was no one in the vicinity able to give First Aid to the casualty.
(2) The designated First Aider from the Security Office, when informed of the incident, rang the Health and Safety Manager before calling for an Ambulance. The statement giving this evidence was challenged, however, by the evidence taken at the Inquest from the Health and Safety Manager.
(3) The First Aider who attended the casualty was herself in shock and unable to carry out mouth to mouth resuscitation.
(4) The Paramedic who initially attended in response to the 999 call said in a statement that on arriving at the large site of W E Rawson Ltd the Ambulance stopped in a small car park but could not see anyone around and had to drive back on to the main road before eventually finding someone stood by a fire exit door. The Paramedic’s statement said that from arriving at the site to arriving with the patient took approximately five minutes.

These factors in combination suggest that the emergency response procedures at W E Rawson Ltd were not sufficiently efficient or effective. Whilst it is unlikely that these factors contributed to Mr Whitehead’s eventual death, they do give rise to the concern that if another emergency were to arise involving a time critical situation, an avoidable death might occur.

Evidence was taken at the Inquest to the effect that the Disaster Recovery Plan at W E Rawson Ltd was reviewed after Mr Whitehead’s death but the conclusion reached that no significant changes were required. I consider that a further review of the standard of First Aid provision is merited along with the actions to be taken in the immediate aftermath of an unexpected occurrence to ensure that the Emergency Services are contacted immediately and steps taken to expedite their arrival with any casualty.