Prevention of Future Deaths reports · 2014

Kevin Pearson

Regulation 28 report to prevent future deaths, reference 2014-0086, written 3 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report3 Mar 2014
Reference2014-0086
DeceasedKevin Pearson
CoronerPaul Kelly
Coroner areaNorth Lincolnshire & Grimsby
CategoryAccident at Work and Health and Safety related deaths
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

ANNEX A 

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.  John Somerscales Ltd. 
Lancaster Approach, 
Immingham DN40 3JZ 
North Lincolnshire 

1 

CORONER 

I am Paul Kelly, Senior Coroner for the  area of North Lincolnshire and Grimsby 

2 

CORONER’S LEGAL POWERS 

I 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. 

3 

INVESTIGATION and INQUEST 

On 13th June 2013  I commenced an investigation into the death of Kevin Graham 
Pearson (d.o.b.17.3.1953). The investigation concluded at the end of the inquest on 25th 
February 2014. The conclusion of the inquest was that the deceased died from severe 
neck and chest injuries caused by being crushed between a moving tractor unit and a 
stationary trailer 

4 

CIRCUMSTANCES OF THE DEATH 

On 11th June 2013 the deceased was connecting a tractor to a trailer and following 
introduction of air pressure to the trailers brakes they released causing forward 
movement of the tractor and trailer, crushing the deceased between the front of the 
tractor and a second stationary trailer. 

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.  –  

That the Company may not yet have ensured full compliance with guidance for the 
activity  undertaken by the deceased provided by the Health and Safety Executive and 
Institute of Road Transport Engineers and ensured all drivers are aware of and 
acknowledged understanding of that guidance. 
ACTION SHOULD BE TAKEN 

6 

In my opinion action should be taken to prevent future deaths and I believe you have the 
power to take such action.  

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 29th April 2014. I 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 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
persons, namely the Health and Safety Executive, Sheffield and to the deceased’s 
family. 

I 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. 

9 

3rd March 2014                                              [ CORONER] 

2

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