Prevention of Future Deaths reports · 2015

Austen Harrison

Regulation 28 report to prevent future deaths, reference 2015-0481, written 13 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report13 Apr 2015
Reference2015-0481
DeceasedAusten Harrison
CoronerDarren Salter
Coroner areaOxfordshire
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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

| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. | sO Director of Hugo Boss UK

1 | CORONER

lam Mr D M Salter, HM Senior Coroner for Oxfordshire.

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 19 June 2013 | opened an Inquest into the death of Austen Harrison, aged 4, who
died on 8 June 2013 at the John Radcliffe Hospital, Oxford. The case was concluded
with a Jury Inquest at Oxford Coroner's Court on Wednesday 25 March 2015. The Jury
returned a Narrative Conclusion as follows:

Austen died at approximately 0545hrs on 8" June 2013 at the Join Radcliffe Hospital,
Oxford. The death was the result of an incident of a mirror falling on him in the Hugo
Boss Store, Unit 27, Bicester Village, on the 4" June 2013 at approximately 2030hrs.

The mirror came to fail on Austen after he moved the wings, causing the unfixed mirror
to become unstable. The jury believe the mirror should have been fixed to a wail and
that wail should have been re-enforced. We do not believe the mirror was fixed to the
wall. Nor are we able to say who moved the mirror to its final position. The mirror was
moved within the store to its position in the fitting room between 14” September and 3”
December 2012.

We believe a risk assessment should have been conducted post-works to ensure the
mirror was fixed securely to the wall based on the fitting instruction document.

We believe there were health and safety systems in place, but are not confident these
systems would have avoided any danger posed by the mirror. In any case, these
systems appear to have not been followed.

Your Company was represented at Inquest by  rcarimereemarnrrac A number of
current and former employees were among the witnesses to give oral evidence
including the former Store Manager, a and the General Manager, f |

4 | CIRCUMSTANCES OF THE DEATH

| realise of course that the circumstances of Austen’s tragic death will be very well
known to you. The circumstances were briefly summarised by the Jury in the Narrative
Conclusion. Austen sadly died from a severe head injury after he was struck by a three
| way mirror which should have been fixed to a reinforced wail but was left free standing.

|

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 make this report to you.

| recognise that, afterwards, Hugo Boss have carried out investigations and reviews in
order to learn lessons and address concerns. | note that a Health and Safety Manager,
was recruited in Jury 2014. | was supplied with a copy of a witness
statement from Lara which sets out some of the matters that have been
addressed and the steps that have been put in place. Itis an on-going process.

The MATTERS OF CONERN are as follows:

1) It was apparent from the evidence of the aforementioned Store Manager and
General Manager that they had received only very basic health and safety training
and no training whatsoever in their management responsibilities in respect of
health and safety. Neither appeared to know of the existence of monthly health
and safety checklists which the store manager is supposed to complete. More
widely, the evidence indicated that there was a lack of understanding within Hugo
Boss about roles and responsibilities in terms of health and safety.

2) The second concern relates to the absence of regular health and safety audits by
a suitably qualified health and safety professional. It was understood that Hugo
Boss’ new health and safety manager is to commence annual audits to check for
compliance in the coming months.

It seemed very likely on the evidence that a health and safety professional,
particularly with knowledge of Hugo Boss store layout and fixtures and fittings,
would have discovered the unsafe mirror.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe that your
organisation have 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. |
may extend the period on request.

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 Interested Persons,
including Austen’s parents.

The Chief Coroner may publish my report and your response 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, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

ES Monday 13 April 2015

Mr D. M Salter — HM Senior Coroner

Responses

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.

Response from Hugo Boss (PDF)
HUGO BOSS

OXFORDSHIRE

CORCNERS OFFICE

FAO Mr D M Salter <u JUN Zr
HM Senior Coroner for Oxfordshire 4 JUN Zo19
Oxfordshire Coroner's Office /

Oxford Register Offi
ond Floor Pe ere RECEIVED wns Ld]

1 Tidmarsh Lane
Oxford
OX1 1NS

03/06/2015
Dear Sir

Re: Inquest touching upon the death of Master Austen Joshua Harrison

| write further to the Inquest into the tragic death of Master Austen Harrison which concluded on
Wednesday 25 March 2015 and your subsequent Report, dated 13 April 2015, made under
Regulation 28 of the Coroners (Investigations) Regulations 2013 (“the Report”).

The Report raises two specific areas of concern relating to health and safety within HUGO BOSS
UK Limited (“Hugo Boss”). Much progress has been made, and continues to be made, since
Austen's tragic death, in relation to health and safety. | set out below some of the measures that
Hugo Boss have implemented to address the concerns raised.

1. The level of training provided to both the Store and General Manager and the
understanding within Hugo Boss about roles and responsibilities in terms of health and
safety.

As you are aware from the evidence filed within the Inquest, on 14 July 2014 Hugo Boss
appointed a new Health and Safety Manager for all UK Hugo Boss stores. As part of that role,
the Health & Safety Manager has undertaken a detailed review of the health and safety training
and guidance provided at every level of the business, with a specific focus being the training
provided at Store and Area / General Manager level. Enhanced health and safety training for
Store and Area / General Managers was re-launched in February 2015 by the Health & Safety
Manager by way of a workshop (attended by Store and Area Managers) focusing specifically on
the newly introduced Health and Safety Management Workbook (“the Workbook’). The
Workbook was launched between 16 February 2015 and 7 March 2015 and also includes a
Workbook Answer, which is effectively a completed Workbook to be used as guidance. The
content of the Workbook is to be reviewed and updated on an annual basis so as to ensure that
(1) it is compliant with any developments in Health and Safety legislation and; (2) it meets the
continually evolving needs of a growing company such as Hugo Boss. The Workbook details
clearly the health and safety responsibilities of every employee (both existing and new-starters)
occupying an in-store management and / or supervisory role. It sets out clearly, for example, that
as a manager in one of UK Hugo Boss’ stores, that person is responsible for the health and
safety of the customers and colleagues that visit UK Hugo Boss’ stores. By way of an example,
two duties of the Store Manager set out in the Workbook are (1) ensuring colleagues are
competent and have received the relevant training for the tasks they carry out; and (2) role
modelling health and safety in store, communicating as required, regularly and effectively to

HUGO BOSS UK LTD 39 Plender Street London NW1 ODT Phone: +44 (0)20 7554 5700 Fax: +44 (0)20 7554 5701

HUGO BOSS

engage the team. The Workbook also includes but is not limited to, the requirement to ensure
that weekly (by way of the daily opening checks) and monthly health and safety checks are
completed and followed up, and that any issues with amenities are identified and reported in line
with Hugo Boss procedures. The Workbook applies to anyone in a managerial and / or
supervisory position in store, including those who run the stores in the absence of the store
managers. This workbook is now part of the management role induction and will be completed
by all new managers in the business by way of promotion or joining the company.

There is a specific section in the Workbook on Risk Assessments and Safe Working Practices,
to ensure that safe systems of work are maintained and any risks have been identified and
controlled.

Following attendance at the workshop, it is the responsibility of every Store, General and Area
Manager to distil the information communicated at both the workshop and contained in the
Workbook to their respective teams. It is the responsibility of those who attended the workshop
to then return to store and complete the workbook and ensure completion by all pre-existing
employees in a managerial and / or supervisory role. For all new starters moving forward
occupying a managerial and / or supervisory role this must be completed within 12 weeks as
part of their induction. Completion of the Workbook must be registered via Formsite, an online
monitoring system, which will be physically monitored by the Health & Safety Manager and
Retail Operations Manager in conjunction with the HUGO BOSS Human Resources
Department, thereby ensuring compliance. Reminders of this mandatory requirement are sent
out via the weekly Hugo Boss Retail Bulletin which is sent electronically to every staff member.
All of these documents are also available on Hugo Boss’ Z drive, where all relevant health and
safety documentation is stored.

In order to ensure that the aforementioned health and safety training is cascaded downwards by
store management and properly implemented by their respective teams, the Health & Safety
Manager also undertakes visits with all Area Managers to stores within their remit to inspect,
review and discuss all matters relating to health and safety, including how to escalate and
follow-up any issues that may be identified. These visits take place regularly and their purpose is
to ensure that Area Managers are able to identify risks and support and coach the Store
Managers under their remit during their own store visits, as they would with any other Key
Performance Indicator.

Health and safety training within Hugo Boss is, of course, not limited to those occupying Store
Manager / General Manager / Area Manager roles and is provided to employees at every level
irrespective of whether or not those employees are located in-store. For example, the Health &
Safety Manager is, on a monthly basis, running health and safety training sessions directed at all
employees based at the HUGO BOSS head office thus ensuring that all stores have the support
of head office in the creation of a safe working environment and culture.

In addition, in August 2015 HUGO BOSS will be launching the e-learnirg Hugo Boss Health and
Safety University Module which is to be completed, as a mandatory requirement, by every new
starter as part of their induction. This Module, much like the Health and Safety Management
Workbook, will communicate the role of each employee in contributing to the creation and
maintenance of a safe working environment and culture, and crucially in the reporting of
potential health and safety hazards and risks.

HUGO BOSS UK LTD 39 Plender Street London NW1 ODT Phone: +44 (0)20 7554 5700 Fax: +44 (0}20 7554 5701

HUGO BOSS

Hugo Boss acknowledges that employee awareness of health and safety must be monitored and
developed on an on-going basis. A number of tools have been created to assist with this
process including daily store health and safety checks and a revised Monthly Store Health and
Safety Inspection Form (completed by the Store Manager and checked by the Area Manager
during their store visits). Both the daily and monthly checks are discussed in more detail below
in Hugo Boss’ response to the second concern raised by the Coroner. In addition Hugo Boss will
conduct an annual Health and Safety Focus Week, the first of which will commence on Monday
21 September 2015. This focus week, attendance at which is compulsory for all HUGO BOSS
employees, will comprise of (1) health and safety refresher training including for example
activities to assist staff in the completion of key health and safety documentation; and (2) a
review of all in-store risk assessments to ensure that all staff are firstly up to date with all health
and safety matters, and secondly to highlight any changes to the assessment format.

The revised health and safety training programme set out above emphasises that in addition to
the managerial responsibilities, accountability for health and safety rests with each and every
employee and sets out clearly the Hugo Boss Health and Safety Policy and, importantly, the
profiles for each role within the Retail Operations side of the business ranging from Sales
Advisor to Area Manager. The Human Resources Department, in conjunction with the Health &
Safety Manager, has revised all role profiles which now properly reflect and highlight the on-
going duties of that employee with regards to workplace safety and compliance with
occupational health and safety regulations, the main emphasis being on identifying and reporting
unsafe working practices or conditions.

Ultimately therefore the improvements that have been, and continue to be, implemented by
Hugo Boss in terms of enhancing employee awareness and embedding a consistent health and
safety culture are two-fold; firstly ensuring that all company literature conveys the roles and
responsibilities of every employee in terms of health and safety (as discussed further below),
and secondly that each employee receives the training necessary to ensure that they are
competent in the implementation of those roles and responsibilities.

. Tike absence of regular health and safety audits by a suitably qualified health and safety

professional.

Hugo Boss recognise that the monitoring of in-store health and safety is key and have put in
place both internal and external checking systems to ensure compliance at every level.

Alcumus SM&MS, independent health and safety consultants, have in addition, been contracted
by Hugo Boss to carry out an annual Hugo Boss Health and Safety Compliance Audit (“the
Audit”) for each UK Hugo Boss store. This annual Audit replaces the audit initially intended to be
conducted by Hugo Boss own Health and Safety Manager. The finalised Audit template and
guidance notes focus on five specific areas; (1) environment; (2) training and communication; (3)
accidents; (4) fire safety; and (5) checks and risk assessment. The Audit will include, but is not
limited to, ensuring that all in-store health and safety documentation remains up to date;
ensuring that in-store health and safety training in respect of the staff at the store is up to date;
ensuring the (new) in-store health and safety notice board is up to date; undertaking an in-store
risk walk; questioning the store staff and management on all health and safety issues and
assessing their understanding; ensuring that any outstanding health and safety issues have

HUGO BOSS UK LTD 39 Plender Street London NW1 ODT Phone: +44 (0)20 7554 5700 Fax: +44 (0)20 7554 5701

HUGO BOSS

been followed up; and undertaking spot checks to ensure that the Monthly Health and Safety
Inspection Form has been completed correctly. Any issues identified as a result of the Audit are
to be followed up by the Store Manager (who will accompany the auditor for the duration of the
Audit during which advice can be provided by the auditor conducting the Audit) and Area
Manager. The Store Manager (with the assistance of the Health and Safety Manager if required)
is responsible for drafting an action plan to demonstrate the actions taken; within 7 days if the
issue is flagged as amber and immediately if the issue is flagged as red (in which case the
Health and Safety Manager must also be notified).

In addition to the health and safety compliance audit, Alcumus SM&MS also carry out
independent Health and Safety Risk Assessments, Fire Risk Assessments and Legionella Risk
Assessments on behalf of Hugo Boss in accordance with Regulation 7 of the Management of
Health and Safety at Work Regulations 1999, in respect of each and every store.

As already alluded to, annual external auditing of health and safety within Hugo Boss is
supplemented by a variety of internal checking systems allowing compliance and emerging
health and safety risks to be monitored on an on-going basis. The internal checking systems can
be categorised as follows:

a. Store Opening Checks

In addition to the snagging list produced the week prior to the opening of a new, re-fitted or
re-furbished store (to be completed in advance of the store opening) checks are undertaken
by Newman Scott Limited, a company specialising in retail and commercial fit-outs, including
on all newly installed mirrors and any mirrors that have been moved to a new location in-
store as a result of a re-fit. Newman Scott will work directly with the Hugo Boss Project
Manager in order to ensure that these checks are completed. Further, following the
installation of a mirror at any new store and / or following a store re-fit or store refurbishment,
a Mirror Installation Review Form must be signed off by the Project Manager, Contractor in
charge of the mirror installation, and Site Foreman confirming that the mirror installation
complies with the required specification. This form is then stored on the Project File for the
relevant store located on the Hugo Boss X: Drive.

b. Store Level Checks

Each Store Manager must complete an online Daily Opening Check (submitted on a weekly
basis and monitored by retail operations and the Area Manager to ensure compliance) and
Monthly Store Health and Safety Inspection Check in respect of their respective store. The
Daily Opening Checklist requires the Store Manager to undertake a daily store walk and to
confirm that “the store [is] free from health & safety hazards and safe to open”. Any issues,
for example with fixtures and fittings, are to be reported immediately to Bellrock, Hugo
Boss's external Facilities Management contractor, and the relevant Area Manager if
required.

The Monthly Store Health and Safety Inspection Form is completed by the Store Manager
and checked by the Area Manager during their frequent store visits which take place, as a
minimum requirement, on a quarterly basis. The Monthly Store Health and Safety Inspection
Check is submitted online via Formsite, the contents of which are then forwarded directly to

HUGO BOSS UK LTD 39 Plender Street London NW1 ODT Phone: +44 (0)20 7554 5700 Fax: +44 (0)20 7554 5701

HUGO BOSS

the Health & Safety Manager. The on-line checking process provides for greater
discernibility and the production of reports highlighting trends in health and safety, including
any recurring health and safety issues.

It is the responsibility of the Store Manager to resolve any issues in the first instance;
outstanding issues are then being escalated to the Area Manager, Bellrock and / or the
Health and Safety Manager and /or facilities manager Again, the requirement for both the
Store and Area Manager to engage in the checking process is an additional tool to ensure
that employees in management roles are fully appraised of their health and safety
responsibilities.

c. Senior Level Monitoring

The Senior Management within Hugo Boss UK are fully committed to the successful
implementation of health and safety processes. The inclusion of health and safety trends
and issues at the Quarterly Review Meetings, attended by all Heads of Departments at
HUGO BOSS, is part of this commitment. Health and Safety is a separate topic on the
meeting agenda and all discussions in this respect are led in the first instance by the Area
Managers, based on pre-prepared reports setting out the progress of the stores under their
remit as compared with the stores’ Key Performance Objectives, including health and safety.
Any health and safety issues raised are discussed amongst the attendees (including the
Managing Director, Retail Director, Finance Director, Head of Shop Construction, Area
Managers and Health & Safety Manager) with a view to formulating an agreed way forward.

Health and Safety is also a separate agenda point at the “Heads of’ Meeting” which is held
on a monthly basis and attended by all of the Heads of Department within Hugo Boss. The
meeting provides a forum for any health and safety issues and actions to be highlighted and
discussed with the full input and support of HUGO BOSS Senior Management. This meeting
is in addition to the weekly health and safety meeting attended by the Health & Safety
Manager, the Hugo Boss Finance Director, and the Head of Human Resources. This weekly
meeting ensures that any immediate health and safety concerns are dealt with promptly and
that all action points are being adequately progressed,

Copies of the documents referred to above are of course available for review by HM Coroner as
desired.

| hope that the above information sets out clearly the steps that have been taken by Hugo Boss in
response to the concerns raised by the Coroner in his Report of 13 April 2015.

Yours sincerel

Managing Director
Hugo Boss UK Limited

HUGO BOSS UK LTD 39 Plender Street London NW1 ODT Phone: +44 (0)20 7554 5700 Fax: +44 (0)20 7554 5701

Related reports

Other reports by Darren Salter

See all →

More reports categorised “Other related deaths”

See all →

Track Darren Salter

See every Prevention of Future Deaths report matching Darren Salter, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.