Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0513, written 25 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Nov 2014 |
|---|---|
| Reference | 2014-0513 |
| Deceased | Richard Turner |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Managing Director
FALCON CRANE HIRE LIMITED
Shipdham
Thetford
IP25 7SD
1
CORONER
I am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK
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 4 February 2014 I commenced an investigation into the death of RICHARD
ANTHONY TURNER. The investigation concluded at the end of the inquest on 18
November 2014. The conclusion of the inquest was medical cause of death: 1a) Multi
organ failure b) Abdominal sepsis c) Trauma to the pelvis and abdomen due to Industrial
accident and short form conclusion: Accidental Death.
4
CIRCUMSTANCES OF THE DEATH
Mr Turner was employed as a Slinger and on 10 January 2014 he was working with a
co-employee, a Crane Driver. Both men were recognised by witnesses to be suitably
qualified and experienced. Both men worked together on a daily basis in the same yard
dealing with the same equipment, namely loading and unloading cranes. On 10 January
2014 Mr Turner attached the lifting equipment to the crane jib section and the Crane
Operator raised the jib to move it. During the manoeuvre the section fell onto Mr Turner
crushing him. He was taken to hospital where he underwent several procedures. Mr
Turner died on 4 February 2014.
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. –
(1) By working closely with the same person and dealing with the same type of work in
the same place, employees can become complacent with regard to health and safety
and the risks involved in their work
(2) Lifting Plans were signed by employees dealing with conducting a lifting operation,
planning and preparation, supervision requirements, and other safety procedures to be
followed which were signed by Mr Turner on 29 November 2011.
1
(3) There does not seen to be any standard procedure in place to remind employees of
these Lifting Plans, risks involved, health and safety issues with regard to the work.
(4) There was evidence of only one “Toolbox Talk” having taken place since the
accident.
ACTION SHOULD BE TAKEN
6
In my opinion action should be taken to prevent future deaths and I believe your
organisation has 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 23 January 2014. I, 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
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:
Health & Safety Executive
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
25 November 2014
SIGNED BY CORONER
………………………………………..
2
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