Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0049, written 15 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2016 |
|---|---|
| Reference | 2016-0049 |
| Deceased | Belinda Wise |
| Coroner | Lydia Brown |
| Coroner area | Leicester City and South Leicestershire |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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. Mr Mike Coupe, Chief Executive. J Sainsbury's plc. Sainsbury’s Store Support Centre, 33 Holborn, London, EC1N 2HT. 2. Mr Mark Hall, Chief Executive, Oadby and Wigston Borough Council, Station Road, Oadby, Leicestershire. LE18 2DR 3. Mr Richard Judge, Chief Executive Health and Safety Executive, Redgrave Court, Merton Road, Bootle, Merseyside.L20 7HS. CORONER | am Lydia Brown, assistant coroner, for the coroner area of Leicester City and Leicestershire South 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 27" March 2015 | commenced an investigation into the death of Belinda Jane Wise. At inquest the determinations were that; On the 6th March 2015 at Sainsbury's, Glen Road, Oadby, Belinda entered the lift Belinda leant against the rear doors and subsequently fell backwards when the doors opened hitting her head. There were no sign/auditory warnings within the lift to indicate the rear doors would open. Belinda died on the 11th March 2015 at University Hospital, Clifford Bridge Road, Coventry and Warwickshire of a left-sided subdural haemorrhage Conclusion — Accidental death Cause of death 1a Left sided subdural haemorrhage 1b Fall 4 | CIRCUMSTANCES OF THE DEATH Mrs Wise was taking warfarin for a diagnosed cardiac condition. She arranged to meet a friend for lunch at a Sainsbury's café and entered the lift to take her to the mezzanine level within the store. She recollected leaning on the lift side, and being surprised when rear doors opened, opposite to where she had entered the lift. There was no sign or auditory warning to alert the passengers of this. She stumbled and fell to the floor, banging her head. Initially she was attended by the store First Aid responder, but appeared to be uninjured. However, a short time later she became unwell and an ambulance was summonsed. She was taken to the local neurosurgical centre for suspected brain injury, and on arrival was deeply unconscious and CT scanning revealed a large subdural haemorrhage with mid line shift. Her condition was thought to be unsurvivable; she was palliated and died 5 days later. 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. — \t was a finding of the jury that there were no signs or auditory warnings within the lift to indicate that the rear doors would open. Evidence taken from the Sainsbury's store and from the Borough Council investigation confirmed that such warnings are not standard or mandatory. In this instance, it was clear from the Evidence that the deceased did not appreciate that the part of the lift that she was leaning was actually the rear doors, as they were not marked in any way. Further consideration should be given to the possibility of making the doors more apparent and distinguishable from the rest of the interior, and also to the sounding of a warning message (that may assist visually impaired passengers) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you 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, namely by 44a April 2016. |, 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 (Family) Chief Executive, University Hospitals Coventry and Warwickshire. | 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 tesponse, about the release or the publication of your, nse by the Chief Coroner. [DATE] 48 BY CORONER] 15th February 2016 is)
2 responses 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.
Health and Safety Executive Chief Executive Dr Richard Judge Mrs L C Brown Red rt Assistant Coroner Sauber = Leicester City & South Leicestershire Bootle The Town Hall ; L20 7HS Town Hall Square Merseyside a LEICESTER LE1 9BG Tel: 0151 951 5766 Your Ref: CEM/GA/00825-2015 http://www.hse.gov.uk/ 8 April 2016 = | Dear Mrs Brown BELINDA JANE WISE Thank you for your letter of the 15 February regarding Mrs Wise's tragic death on 6 March 2015. Your letter recommended that consideration be given to making lift doors more apparent and distinguishable from the rest of the interior of the lift, and also to the sounding of a warming message (that may assist visually impaired passengers). | can confirm that the information provided to you during the inquest is correct; currently such warnings or signs are not mandatory. The design and installation of lifts in the UK are governed by the Lifts Regulations 1997 which are based on the European Lifts Directive (95/15/EC). The Regulations impose duties on manufacturers and installers of lifts to design and install their lifts to meet essential health and safety requirements detailed in the Regulations. The Regulations do not address the two issues you raise. In order for the UK to legislate in this matter HSE would need to either propose new legislation, which the Secretary of State would have to approve, or request the revised Lifts Directive include such provisions. Any new UK legislation would need to be evidentially based to satisfy the Secretary of State and UK stakeholders. The Health and Safety Executive (HSE) is not aware of any previous incidents of this nature. We have also discussed the matter with the UK lift industry and key users and they are also unaware of any similar incidents. The HSE is therefore not proposing to introduce new UK legislation in this matter at this stage. We propose two actions to raise awareness of the incident with relevant standard setting bodies, so that they can form a view on whether further action might be needed: First, the HSE represents the UK at a European forum for lifts. This forum discusses issues across the lift industry and raises concerns that feed into future Directive revisions when they arise, for consideration. We will raise this incident as an issue for concern at the next planned meeting in 2016, asking if other Member States have any experience of such incidents. This will also be very timely as the process to revise the Lift Directive is due to start next year. Second, we will also ensure that this incident is raised with the relevant BSi committee at their next meeting. This committee also feeds relevant incidents into CEN, the European standards authority for the European Commission, for the consideration in future revision of the Lifts Directive. As you no doubt appreciate, even if changes were to be agreed by these organisations, these would take time to happen. Additionally, if these matters were included in the revision they would only apply to new lifts placed on the market, not previously installed lifts unless they were substantially refurbished. Yours sincerely, la jee Dr Richard Judge Chief Executive
e® Borough of Oadby & Wigston INTERIM HEAD OF COMMUNITY SERVICES Mr Mike Coupe Mr Stephen Glazebrook J Sainsbury Pic Internet: Sainsbury Store Support Centre 33 Holborn London EC1N 2HT Please ask for: Cheryll Stew Tel: 0116 2888961 Date 11” March 2016 Dear Sir, Re: Belinda Jane Wise. Coroner’s Court Hearing 10"-11" February 2016 Sainsbury Plc, Glen Road, Oadby, Leicester | write in connection with the above case and the subsequent coroner's report of 15” February 2016 which details the court's matters of concern as below ‘It was the finding of the jury that there were no signs or auditory warnings within the lift to indicate that the rear doors would open. Evidence taken from the Sainsbury’s store and from the Borough Council investigation confirmed that such warnings are not standard or mandatory. In this instance, it was clear from the Evidence that the deceased did not appreciate that the part of the lift she was leaning on was actually the rear doors, as they were not marked in any way. Further consideration should be given to the possibility of making the doors more apparent and distinguishable from the rest of the interior, and also to the sounding of a warning message (that may assist visually impaired passengers).’ Although there are no legal requirements to install signage or warning messages in the lift, the coroner's opinion is that future deaths could occur if this is not done. With this in mind, this council strongly recommends that Sainsbury carry out the work suggested by the coroner. A visit will take place to the store within the next month to check that the required work has been done. ( 5 Council Offices: Station Road, Wigston, Leicestershire LE18 2DR Tel: (0116) 288 8961 Fax; (0116) 288 7828 Se Printed on recycled paper INVESTOR IN PEOPLE 2 ek Pap o this matte f you would like jiscuss th etter further Health Office: C.c. Mrs L C Brown, Assistant Coroner, The Town Hall, Town Hall Square, Leicester, LE1 9BG Simon Eyley From: Neil Lennox <Neil.Lennox@sainsburys.co,uk> Sent: 12 April 2016 15:47 To: leicester-coroner Subject: Belinda Wise - Regulation 28 report Dear Mrs Brown, | am writing on behalf of our Chief Executive — Mr Mike Coupe in relation to the letter and Regulation 28 report that we have received from yourselves in relation to the above inquest. The lift that we have installed at our Glen Road store is of a standard construction and installation and is similar to those installed in a small number of stores in our estate. Given that fact we have taken the view that were we to take action at this store we should also take similar action at other stores and, in addition similar action would need to be taken on other similar lifts installed in other premises. To that end | have been discussing this incident with Richard Judge at the HSE who also received a copy of your report as they are the body that would set the standards relating to the lift design, installation and signage. Richard has promised to send me a copy of his response in due course and, once we have received this we will take any appropriate action in the Glen Road store as well as those other stores in our estate. | would be grateful if you would bear with us until we have had a chance to review the response prepared by the HSE. Yours sincerely | of Safety & Insurance | Corporate Services - Group Safety & Insurance Sainsbury's Supermarkets Ltd | 33 Holborn, London | EC1N 2HT neil.lennox@sainsburys.co.uk | 0207 695 6202 / 07798 571199 You can live well forless than you thought at Sainsbury's based on price perception data You can live well for less than you thought at Sainsbury's based on price perception data This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the system manager (postmaster@sainsburys.co.uk) and delete it from your system. J Sainsbury ple (185647 England) Sainsbury's Supermarkets Ltd (3261722 England) Registered Offices: 33 Holborn, London, EC1N 2HT
See every Prevention of Future Deaths report matching Accident at Work and Health and Safety related deaths, 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.