Prevention of Future Deaths reports · 2013

Garrett Joseph Franklin Elsey

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 report22 Nov 2013
Reference2013-0316
DeceasedGarrett Joseph Franklin Elsey
CoronerTerence G. Moore
Coroner areaAvon
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

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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