Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0316, written 22 Nov 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Nov 2013 |
|---|---|
| Reference | 2013-0316 |
| Deceased | Garrett Joseph Franklin Elsey |
| Coroner | Terence G. Moore |
| Coroner area | Avon |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. HSE’s Waste and Recycling Sector Team 4 | CORONER lam Terence G. Moore, Assistant Coroner, for the area of Avon 2 | CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] 3 | INVESTIGATION and INQUEST On 13" December 2012 = an investigation into the death of Garrett Joseph Franklin ELSEY, Aged 22, commenced. The investigation concluded at the end of the inquest on 7th November 2013. The conclusion of the inquest was Accidental death. 4 | CIRCUMSTANCES OF THE DEATH Body found at New Earth Solutions refuse site in Avonmouth, Bristol amongst waste which had been dumped by a refuse lorry that had been collecting rubbish from various locations in the City 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — AHSE document entitled “People in Commercial Waste Containers”, “Waste 25”, was produced at the inquest as evidence. It is of concern that this important document may not have been read by the waste industry and possibly some sort of alert system could be set up ensure that everybody in this industry is aware of this document. 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] have the power to take such action. 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25" January 2014 |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 | COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following interested Persons — the family and May Gurney Limited Tam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the releas¢ or the publication of your response by the Chief Coroner. [22/11/13] sk UJ \ Se a
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