Ashley Mark Holden · Prevention of Future Deaths report

On 19 November 2018 I commenced an investigation into the death of Ashley Mark Holden, aged 27. The investigation concluded at the end of the inquest on 11 December 2019. The conclusion of the inquest was that Mr Holden died as a result of an accident, the medical cause of death being:

1a. Head Injury

1. On 10 November 2018 Ashley Holden was employed as an HGV driver. He was instructed by his employer to visit Staples Farm, Main Road, Stickney. Boston to collect a quantity of straw bales.
2. Although his employment had not commenced until 7 November 2018 he had visited that farm on previous occasions and had collected a similar load of bales without incident.
3. On 10 November, as previously, the trailer was loaded for him by farm operatives and the bales were loaded in accordance with the normal pattern.
4. The trailer had an extendable bar fitted to the rear which lengthened the trailer bed by approximately two feet. After the trailer had been fully loaded, Mr Holden noted that the bales, as loaded, were overhanging the trailer bed. He requested that a number of bales be removed from the rearmost section of the trailer as he wished to check that the bar was fully extended.
5. The farm operative removed a total of 9 bales from the very rear of the trailer, following which Mr Holden and the operative confirmed that the bar was fully extended. It was pulled out by an additional couple of inches only.
6. As that occurred, two of the remaining bales, being unstable, fell from the trailer, one of them striking Mr Holden and forcing his head onto the extended trailer bar where he sustained fatal injury.

I received evidence that;

1. Fatalities from falling bales are an acknowledged risk within agriculture with a number of fatalities annually.
2. There are two specific guidance documents available to the public which are relevant to this issue;
• Department of Transport Code of Practice, “Safety Loads on Vehicles” (2002)
• Health and Safety Executive (HSE), “Safe Working With Bales in Agriculture” (2012)
3. The two pieces of guidance are not consistent in the approaches that they suggest and indeed the later guidance does not reference the earlier guidance.
4. There is no definitive guidance provided to the industry in relation to the stacking or unstacking of bales, or in relation to the loading and strapping of loaded trailers in a manner which takes account of the different sizes and composition of bales, and/or different trailer sizes and configurations.
5. The absence of specific guidance on this issue creates a risk of the development of unapproved and potentially unsafe individual practices, with the consequential risk of future deaths.
6. The provision of definitive guidance would be welcomed by those working within agriculture.