Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0328, written 5 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Dec 2013 |
|---|---|
| Reference | 2013-0328 |
| Deceased | Karl Doran |
| Coroner | Andrew Tweddle |
| Coroner area | County Durham and Darlington |
| 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 THIS REPORT IS BEING SENT TO: 1. Director, Beamish Museum, Beamish, Co Durham DH9 ORG 2. HSE, Alnwick House, Benton Park View, Newcastle upon Tyne CORONER 1am ANDREW TWEDDLE Senior Coroner, for the Coroner Area of County Durham and Darlington 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. (see attached sheet) INVESTIGATION and INQUEST On 26" July 2012 | commenced an investigation into the death of, Karl Doran aged 7 years. The investigation concluded at the end of the inquest on 2"! December 2013. The conclusion of the inquest was Accidental Death. CIRCUMSTANCES OF THE DEATH The deceased was a seven year old boy, who together with his father, were volunteers at Beamish Museum in County Durham ill drove a steam roller around the Museum's roads and was accompanied by his son, who at various times on the day in question rode on the steam roller/at the back of the steam roller/standing on an “A” frame linking the steam roller to a trailer/sitting on said “A” frame. Both father and son had been engaged in similar activities at Beamish on a number of occasions in the past, though this was the first occasion when they had used this combination of steam roller and trailer. There was no clear witness evidence as to where Karl was immediately prior to him failing and almost immediately thereafter being crushed by the heavy steel wheeled trailer. Karl's death would have been almost instantaneous. 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. - (1) Beamish had not carried out a appropriate risk assessments to ensure the safety of volunteers such as Karl and his father when engaging in activities around the museum site. There was no direct or in-direct managerial supervision of these volunteers activities. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action. Action should be taken by Beamish to carry out a full and detailed risk assessment of all aspects of the use of steam powered vehicles in the museum to ensure the safety of staff, volunteers and the public and to exercise proper managerial contro! over such people to ensure their safety. HSE gave evidence that there is little specific guidance on the issue, though comparable equivalent advice can be gleaned from the use of agricultural machinery, though the National Traction Engine Trust does give guidance and assistance to members and others with regard to the safe use of traction engines. HSE accepted in evidence that it has an educational role in health and safety matters and should disseminate the lessons. learnt from this case to as wide a possible audience as is possible who might benefit from it, including, but not exclusively, the National Traction Engine Trust. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30" 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons | have also sent it to the following who may find it useful or of interest Darlington Safeguarding Board ‘ounty Durham Safeguarding Board | am 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 release or the publication of your response by the Chief Coroner. 5" December 2013 A Andrew Tweddle LLB H M Senior Coroner County Durham and Darlington
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