PETER JOHN BUCKLE · Prevention of Future Deaths report

On 26 March 2015 I commenced an investigation into the death of PETER JOHN BUCKLE, AGED 67 YEARS. The investigation concluded at the end of the inquest on 29 OCTOBER 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Traumatic Subarachnoid Haemorrhage b) Hinge fracture of skull. Conclusion: Misadventure.

On 24 March 2015, whilst at work, Mr Buckle was instructed to load rubbish onto his trailer. The telehandler was not working so it was suggested the rubbish was to be thrown into the trailer by hand. It was then felt the sides of the trailer were too high. It was decided to prop open the tailgate with a post. A post was propped against the tailgate but it slipped causing the tailgate to fall resulting in injury to Mr Buckle. He was airlifted to Addenbrooke's Hospital where he died later that day from his injuries. Health and safety procedures were in place at the time of the incident and since the incident a “Stop and Think” campaign which had been identified earlier, has been put in place.

(1) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe.
(2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for health and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level”.