Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0425, written 3 Nov 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Nov 2015 |
|---|---|
| Reference | 2015-0425 |
| Deceased | Peter Buckle |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Managing Director Wayland Farms Limited Little Melton Food Park Beckhithe Little Melton Norwich NR9 3NP 1 | CORONER | am JACQUELINE LAKE, senior coroner, for the coroner area of NORFOLK 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. 3 | INVESTIGATION and INQUEST On 26 March 2015 | commenced an investigation into the death of PETER JOHN BUCKLE, AGED 67 YEARS. The investigation concluded at the end of the inquest on 29 OCTOBER 2015. The conclusion of the inquest was Medical Cause of Death: 1a) Traumatic Subarachnoid Haemorrhage b) Hinge fracture of skull. Conclusion: Misadventure. 4 | CIRCUMSTANCES OF THE DEATH On 24 March 2015, whilst at work, Mr Buckle was instructed to load rubbish onto his trailer. The telehandler was not working so it was suggested the rubbish was to be thrown into the trailer by hand. It was then felt the sides of the trailer were too high. It was decided to prop open the tailgate with a post. A post was propped against the tailgate but it slipped causing the tailgate to fall resulting in injury to Mr Buckle. He was airlifted to Addenbrooke's Hospital where he died later that day from his injuries. Health and safety procedures were in place at the time of the incident and since the incident a “Stop and Think” campaign which had been identified earlier, has been put in place. 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) Although a risk assessment was in place for the original method of carrying out the task (with the telehandler and grab), once this method was no longer viable a risk assessment was not carried out or considered prior to steps being taken with regard to the next method under consideration, namely to throw the rubbish over the side of the trailer; in that the trailer was reversed to the rubbish site, a telephone call was made to 2 other employees to assist and protective equipment was being obtained. This left Mr Buckle to assume the work was to be carried out in this way, whether or not the Site Manager was of the view the method of work was still under consideration. In any event this method of carrying out the work was blatantly unsafe. (2) The employees left at the site of the rubbish, decided on a third method of carrying out the work, without any thought for heaith and safety. Although health and safety induction training had been undertaken and managers had received further training, a health and safety culture was not apparent from the evidence, particularly at “ground level’. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE ” You are under a duty to respond to this report within 56 days of the date of this report, namely by 31 December 2015. |, 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: (via Thompsons Solicitors) Health & Safety Executive (Paul Unwin) RoSPA | 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. 3 November 2015 Jacqueline Lake Senior Coroner for Norfolk
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
_ Wayland Farms Limited Little Meiton Food Park ~~ Tel 01603 813830 FARMS I rm Fax 01603 812091 Our reference: 2015/1387770/S EH Wayland Farms RMS/NFUQ563-2 Your reference: Dear Ms Lake Mr Peter Buckle (deceased) v Wayland Farms Ltd We write further to Regulation 28: Report to Prevent Future Deaths dated 3 November 2015. In relation to your concerns detailed in the Report we confirm that since Mr Buckle’s accident the following measures have been implemented: New Programmes: Wayland Farms Limited has put in place new programmes to deal with health and safety since the accident. We refer to Page 2 of the Health & Safety Executive’s Fatal Incident Report dated 28" April 2015 in this regard (copy attached marked Exhibit “1"), A training program based around behavioural safety with the aim of improving the safety culture within Wayland Farms Ltd has been completed, this was a blend of theory and practice in both an engaging and thought- provoking way to enable smarter decisions and actions in relation to tasks and situations occurring that fall outside of what is expected to be the normal procedure or activity. This program called “stop and think” has been designed to help the worker understand the significance and importance of planning for key decisions’ when activities or procedures have a need to be amended due to a change in circumstance. The significant element of this program being the worker is asked to stop and contact their Unit Manager at the critical point; the decision and task planning is then carried out as a duel role with both levels of competence, the objective being to prevent the worker taking quick or hasty actions in an “act now, think later” way. Management Registered in England No: 6727508 Wayland Farms Limited Little Melton Food Park <n Tel 01603 813830 FARMS UTD Fax 01603 812091 further training ensuring that there is an emphasis on the necessity for communication cascading from the manager to the workers. Training: The Solicitors on behalf of Wayland Farms Ltd, Robin Simon LLP, have also offered to speak to the directors and managers in addition to training being provided by Wayland Farms Health & Safety and Environmental Manager. it is believed that an external person speaking to the directors and managers will assist in emphasising and ensuring that manager understand their responsibilities, following which the managers can then reiterate and enforce health and safety issues with employees, Disciplinary Action: Wayland Farms Ltd acknowledges that disciplinary action needs to be taken where there is a breach of health and safety procedures. Written Documentation: Wayland Farms Ltd acknowledge that there needs to be greater written documentation in relation to safety communications, and risk assessments regarding what happens when things change in the course of the work being undertaken. Wayland Farms Ltd plan to take steps that safety critical communications are confirmed in writing as and when carried out. Plan of Actilon/Further Re-iteration: It is apparent that the measures referred to above are being undertaken on a continual improvement basis with enhanced focus since the Claimant’s accident. With regards to enforcement and the associated training, It Is anticipated that operational directors will have received the legislation update and guidance pertaining to this during the last 2 weeks in January 2016, A new Health and Safety Audit has just been completed and a trial completed in December 2015, The new Audit incorporates staff interviews to validate the knowledge and understanding of the information, instruction, training and supervision provided by Wayland Farms Ltd. The new Audit will be carried out per unit annually, and will incorporate 10% of staff being interviewed. Registerad in England No; 6727508 ange Wayland Farms Limited FARMS Tm Fax 01603 812091 If you have any queries please do not hesitate to-contact us. Yours sincerely op : Glenn Dams Charles Bowes Managing Director Director Registered in England No: 6727608
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