Prevention of Future Deaths reports · 2015
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 report | 13 Apr 2015 |
|---|---|
| Reference | 2015-0481 |
| Deceased | Austen Harrison |
| Coroner | Darren Salter |
| Coroner area | Oxfordshire |
| Category | Other 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: 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
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.
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
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