Alan Walsh · Prevention of Future Deaths report

I opened an investigation into this death on 16.10.14 after the deceased had fallen from a ladder and died the same day from injuries sustained in the fall. The matter was investigated by the HSE. An inquest was opened on 26.02.16 and concluded before a jury on 18th January 2017. Accident was the conclusion of the jury as to the death.

The deceased fell from a 2.5m Combination (Combi 100) Youngman's A ladder whilst inspecting a fault in a 12.5 foot or 3.8m ceiling void at Eltham Leisure Centre. The deceased fell with the ladder, which was found under the deceased, and was deformed with missing spigots. The jury reached no conclusion on why the accident had occurred. The deceased was experienced in use of this ladder.

████████ HM Inspector of Health and Safety, was reluctant to give an opinion. But the court inspected the damaged and undamaged ladders and heard that:

1. The inspector advised that the spigots or stops were safety critical. They maintain the position of middle and lower sections relative to each other in the A mode, to ensure that they cannot be separated. The lower spigot on C is to stop C section sliding up too far.
2. The role of the spigots was not appreciated by the salesperson from ladder hire company, (which has since drawn attention to these in their hire agreements) nor by the assistant to the deceased. HSE had not issued any statements on these.
3. The inspector concluded that the ladder was erected in the A position with 4 rungs showing above apex at the time of its usage in the Leisure Centre.
3. He said that the positions adopted by the deceased on the ladder were safe and its use was within the safe use intended by the design. The ladder was not being footed at the time.
4. He said that premature opening of the ladder without undue force prior to erection can cause the spigots to suddenly shear off.
5. He agreed that the deformation of the ladder could not have been present before the accident as the ladder could not be put back together in the used position.
6. He said that if the ladder was not locked properly at the apex it would on the balance of probabilities collapse on usage. If it was locked it would not be in the position and state it was after the accident. If it fell with the deceased, as the jury concluded, ████████ concluded it was not locked.

There would appear not be awareness of the safety critical role of the spigots on this ladder, nor the fact that they can easily and inadvertently be sheared off, on premature opening of the ladder. Whilst the absence of these spigots was not found to be the cause of this accident, they may have had a role in the injuries sustained and the implications of the lack of awareness may create risks to health and safety.