Prevention of Future Deaths reports · 2016

Arthur Mason

Regulation 28 report to prevent future deaths, reference 2016-0128, written 1 Apr 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report1 Apr 2016
Reference2016-0128
DeceasedArthur Mason
CoronerJacqueline Lake
Coroner areaNorfolk
CategoryAccident at Work and Health and Safety 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 (1)

NOTE: This form is to be used after an inquest.

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

Maurice Mason Ltd,
Fincham,

King's Lynn,
Norfolk

PE33 9DQ

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 10 JULY 2014 | commenced an investigation into the death of ARTHUR CAXTON
MASON, AGED 21 YEARS. The investigation concluded at the end of the inquest on 18
MARCH 2016. The conclusion of the inquest was medical cause of death: 1a)
Asphyxiation and short-form conclusion: ACCIDENTAL DEATH

4 | CIRCUMSTANCES OF THE DEATH

On 9 July 2014 Mr Mason was cleaning the inside of a grain bin at Hall Farm, Fincham,
King’s Lynn, Norfolk. He was standing on moving grain whilst his colleague went to
close the hatch shutter. When he returned Mr Mason was beneath the grain. Following
attempts to rescue Mr Mason by colleagues and.emergency services, his body was
recovered through an access hatch and he was pronounced dead at the scene.

3 | 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) As at July 2014 no member of staff had undergone fraining in respect of assessing
risks and carrying out Risk Assessments. Following Mr Mason's death, one member of
staff involved in risk assessments has undergone training. This member of staff is
involved in the administration side of documents. Other, senior, members of staff
involved in carrying out risk assessments have not undergone any such training and
from the evidence did not appear to fully accept risks as set out in Health & Safety
Executive documentation, preferring to rely on their own “experience and common
sense”, :

(2) It was unclear from the evidence that staff involved in.carrying out Risk Assessments
recognised the risks of carrying out various tasks on the farm. The current document
“Procedure for Cleaning out Grain Bins” does not recognise any risks or hazards in
carrying out the tasks and it was not clear from the evidence a Risk Assessment is in
place for this new procedure, introduced following and as a result of Mr Mason's death.
(3) The “what to do in'an emergency” Sheet in place as at July 2014 contained a list of
persons to contact and telephone numbers and coordinates to pass to emergency
services. There was no Emergency Plan in place. This has not changed following Mr
Mason's death. Although the grain bins are not to be entered by any personne! on
cleaning, it was clear from the evidence, there are other hazardous areas on the farm.
These “Emergency Sheets” are currently in use and there is no plan or procedure in
place for employees to follow should another emergency occur.

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.

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 27" May 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 seni a copy of my report to the Chief Coroner and ‘to the following Interested
Persons: .
Health & Safety Executive
| have also sent it to:

RoSPA — who may find it useful. or of interest

| 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 response by the Chief Coroner.

1 April 2016 eee \ hate ene Venenenseeene

Jacqueline Lake
Senior Coroner for Norfolk

YOUR RESPONSE

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 Maurice Mason Ltd (PDF)
~- MAURICE MASON LTD.
~ HALL FARM, FINCHAM,
KING'S LYNN, NORFOLK, PE33 9DQ

_ TELEPHONE:
~ FACSIMILE: i

15" June ‘16

Attn: Jacqueline Lake

April 16 and In particular to
“to.action to be taken:

Herewith Is thé response to thé Corbner’s Report and letter, date
Section 5 relating to the Coroner's concerns and Section'6 relati

Section 5

~ 1). For clarification, as of July 2014 theré was a member of staff that had undergone training In
. -Yespect of aésessing risk and carrying aut risk assessments. This is EEE who held a
valid \OSH Certificate (copy encloséd) and was part of the management team over seelng
Health and Safety within the Companiy.. He has 15 years of experience, 10 of those years before
joining Maurice Mason Ltd (mM); MML Have now undertaken to provide extensive tralning of
‘thiore staff In the mariagement.of health and safety using the accredited [OSH scheme; Please
see the below response under Sectidn 6 for full details. ‘itis also of note that
who provided evidence at the Inquést In relation to thé production of risk assessments and risk
management is no loriger an employee of MML.

2) The Company is saddened that they were not able td:get across to the Coroner that their staff
endeavoured to understand the risks involved and wishes to.réiterate that all staff were
working to the best of thelr abilities at all times. MML ishes to express that they have In the
past and will continue to strive to achieve good health aid Safety practices.

A

Section 6

MML has taken the actions set out below in order to comply with the Coroner's Report and In order to
further review health and safety across Its business, not just In respect of the areas highlighted by the
Coroner's Report. In relation to practices of the farm concerning the cleaning of grain bins It is now
the.case that no personnel whatsdever.are to enter the grain bins at any time for cleaning, or Indeed
any other purposes. This practice no longer forris part of any work at MML. Therefore the potential
tisks-in relation to working inside the grain bins have been eradicated. As a result there is no
remaining risk on site of working in a confined space ~ such that was the subject of évidence at the
inquest.

. DIRECTOR; H, MASON
REG, OFFICE AS ABOVE. MEG. NO. 443412 ENGLAND /3

With regards to the specific grain store building, anew risk assess ent Has: been done alon, 1
method statement, ‘it is now more detalled and addresses the risks of the riewW method of work. “A
copy is attached, This how addresses the risks: that are present In ‘the new cleaning method and the
appropriate method of work for cleaning the bins. This document was updated as result of a visit from
the HSE, after the Inquest. A version of this updated document will also be sent independently to the
HSE and it will also be subject to further review by Cope Safety Management Ltd (see below).

In order to address the Coroner's concerns and to address safety | issues ‘across MML. the Cothpahy has
_ instructed Cope Safety Management Ltd (esmt) (qualifications attached) to review and amend: ~

a) Health and Safety Policy

b)- Béspoke risk assessments including as appendixed to this document, a new risk assessment for
the cleaning of the grain bins.

c} Bespoke safe systems of work, to include emergency plans.a as appropriate (also environmental)

d) Employee H+S handbook OHS

9) Site safety inspections (4 per year) .

~ 4) “Tool Box” talks hald’on site with staff, coinpiete with appropiiate i ature

g) lriternet access to CSML updated H+S dociirientation, to keep MML updated with current
legislation along with telephone contact/support.

h) Quarterly updates on H+S matters

CSML becomes MML’s nominated safety advisor. This is a two year contract, formal signing was 2a"
April ‘16 {copy of agreement enclosed, please note that It {s Optton 1 that Is being taken}. ; :

To broaden MML’s understanding of Health and Safety and to.strengthen our abllity to ensure that.
that staff who are responsible for health and safety understand the issues and risks Jnvolved, further
formal training has been booked as set out below. In particular:- ‘

L  “IOSH Directing Safely” (1 day, to be completed 27" July 16)
i. “IOSH Managing Safely” (4 days, to be complated 27" sept 16)
mw. 1% Ald at Work (3 days, date to be confirmed)

a ‘ce manager)
BE (f2ctory ranager)

|. “IOSH Managing Safely” (4 days, cotnplated ao" June 16)

%

. ei: manger)

I. “(OSH Mariaging Safely” (4 days, to ke ‘gmpleted 22 June 16)

There will bé further training for staff members In more focused aréas to strengthen staff involvement
o and understanding. It Is hot possible at this time to o give detalls but it will be on the advice and’ ‘with
‘Input from CSML ; vee

As refétred to above emergency ‘plans will bé specif cally reviewed by cSML and prepare as “and
where appropriate on the advice of CSML and to address the concerns of the Coroner In relation to.
Emergency plans: At the tine of the aécident there were two fully trained and current, first aiders-on

site, These ( There has been a fully
maintained defibrillator on farm since 30" Jan ‘15; with open access. All MML staff have been fully
trained in Its use along with first. ald training.

_ Conclusion
Maurice Mason Ltd has striven to comply with The Health and Safety at Work Act 1974, It recognises
that this process Is a Ilving one and needs continue work and improvement. :

MML believes that It has responded to the Coroner's report actively and positively but it wil continue —
to work both with CSML and the HSE, where necessary, to ensure high standards of practice are
adopted across Its site.

It is difficult to fully articulate the importance that MML attaches to adhering to the highest standards —
of health and safety practice on site, both In the past and going forward.

|, as the director of MML, lost my son. ;

Yours faithfully

Miso
|

%s

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