Prevention of Future Deaths reports · 2016

Javaid Iqbal

Regulation 28 report to prevent future deaths, reference 2016-0023, written 22 Jan 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report22 Jan 2016
Reference2016-0023
DeceasedJavaid Iqbal
CoronerKevin McLoughlin
Coroner areaManchester (West)
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.

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. 

KK Security Services Limited, trading as KAM Security 

1  CORONER 

I am Mr Kevin McLoughlin, an Assistant Coroner, for the Coroner Area of 
Manchester West 

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 the 9th December 2014 an investigation was commenced into the death of 
Javaid Iqbal, aged 28.  The investigation concluded at the end of the inquest on 
18th January 2016. The conclusion of the inquest was Misadventure arising from 
the medical cause of death due to 1a) Carbon Monoxide poisoning due to 1b) 
Inhalation of Products of Combustion. 

4  CIRCUMSTANCES OF THE DEATH 

On Friday night, the 5th / 6th  December 2014 Javaid Iqbal was working as a 
security guard at a construction site at Queen Street, Leigh, based in a site 
portacabin. Heat and light was being provided by a mobile generator located 
near the portacabin. During the evening of Friday 5th December the generator 
failed leaving Mr Iqbal without light or heat on a cold night. He reported the 
matter to various managers but no action was taken to assist him. Around 3am 
Mr Iqbal obtained a bag of charcoal from a 24 hour Tesco Store and used this to 
light a fire in a wheelbarrow placed inside the portacabin in an attempt to keep 
warm. He died from the carbon monoxide fumes produced by the fire. 

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) Javaid Iqbal was working alone on the night of the 5th - 6th December 
2014. It was very cold that night. The generator supplying heat, 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (2) Despite reporting this situation to his employer and the relevant control 
room, he was left to devise a method of keeping warm by himself. 
(3) Mr Iqbal did not have appropriate clothing to protect him from the cold, 
even though he was required to make periodic checks outside during the 
course of the night. 

(4) As a lone worker at night, Mr Iqbal needed clear instruction as to how to 

respond to the situation that had unexpectedly arisen. 

(5) Clear written instructions should be provided by the employer 

accompanied by suitable training so as to ensure adequate provision is 
made for the welfare of other lone night security guards both as to  
i. 

The personal protective equipment and clothing needed on a cold 
night when they are expected to work outside 
The minimum acceptable temperature of the premises they are 
expected to work in. 
Their authority to leave site without loss of pay should it prove 
too cold to work and they are unable to obtain instructions from 
their employer or controller as to the remedial action to be taken. 

ii. 

iii. 

6  ACTION SHOULD BE TAKEN 

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 18th March 2016. 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: 

1)  The family of Javaid Iqbal  
2)  The HSE - 
3)  Greater Manchester Police – 
4)  Veritas Security Southern Limited, Unit 3, Mill Road, Totton, 

Southampton, SO40 3AE 

5)  North Midlands Construction PLC – 

 – Nunn Close, The 

County Estate, Huthwaite, Sutton in Ashfield, Nottinghamshire, N917 
2HW 

6)  Security Industry Authority, PO BOX 49768 London WC1V 6WY 

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 

2

 
 
 
 
 
 
 
 
 
 
 
 
 
 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  Dated 

Signed 

22nd January 2016                   

Mr Kevin McLoughlin 

3
Also filed under 2016-0023: Iqbal-2016-0023.pdf
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. 

Tesco Stores PLC 

1  CORONER 

I am Mr Kevin McLoughlin, an Assistant Coroner, for the Coroner Area of 
Manchester West 

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 the 9th December 2014 an investigation was commenced into the death of 
Javaid Iqbal, aged 28.  The investigation concluded at the end of the inquest on 
18th January 2016. The conclusion of the inquest was Misadventure arising from 
the medical cause of death due to 1a) Carbon Monoxide poisoning due to 1b) 
Inhalation of Products of Combustion. 

4  CIRCUMSTANCES OF THE DEATH 

On Friday night, the 5th / 6th December 2014 Javaid Iqbal was working as a 
security guard at a construction site at Queen Street, Leigh, based in a site 
portacabin. Heat and light was being provided by a mobile generator located 
near the portacabin. During the evening of Friday 5th December the generator 
failed leaving Mr Iqbal without light or heat on a cold night. He reported the 
matter to various managers but no action was taken to assist him. Around 3am 
Mr Iqbal obtained a bag of charcoal from a 24 hour Tesco Store and used this to 
light a fire in a wheelbarrow placed inside the portacabin in an attempt to keep 
warm. He died from the carbon monoxide fumes produced by the fire. 

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) The packaging of the charcoal provides instructions which indicate it should 
not be used indoors. The warning is not given much prominence and does not 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 draw attention to the risk of death from carbon monoxide poisoning if used 
indoors.  

6  ACTION SHOULD BE TAKEN 

In my opinion urgent action should be taken to prevent future deaths and I 
believe you and/or your organisation have the power to take such action by 
having your suppliers review the warnings provided on the packaging of bags of 
charcoal and / or BBQ sets with a view to highlighting the risks involved of 
lighting a BBQ indoors.    

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 18th March 2016. 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: 

1)  The family of Javaid Iqbal  

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  Dated 

Signed 

22nd January 2016                   

Mr Kevin McLoughlin 

2

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