Mark Seward

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. Mr Colin Wood, Chief Executive, Construction Plant-hire Association, 27/28 
Newbury Street, Barbican, London EC1A 7HU 

1 

CORONER 

I am David Clark, Assistant Coroner for the coroner area of Warwickshire. 

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 28 May 2015, I commenced an investigation into the death of Mark Richard Seward, 
aged 49 years. The investigation concluded at the end of the jury inquest on 31 March 
2016. The conclusion of the jury was that Mr Seward died from a head injury and that his 
death was the result of an accident. 

4 

CIRCUMSTANCES OF THE DEATH 

Mr Seward was an experienced fitter, mechanic and engineer who had started work at 
AGD Equipment Limited (AGD) in Stratford-upon-Avon on 10 May 2015. On 27 May 
2015, in the course of his employment, he was using a portable Enerpac pump to test a 
cylinder for an oil leak. At 11.19, the valve block on the cylinder fractured due to 
excessive pressure. The resulting explosion caused an ejection of metal and other 
debris at high speed. Mr Seward was crouching at close proximity to the cylinder. He 
was not wearing protective headware and was not shielded by a protective screen. He 
was struck by debris, resulting in a serious head injury. He was taken by air ambulance 
to University Hospital, Coventry, where he died at 14.35 the same day. 

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 could 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)  There was a lack of clarity as to what type of activity amounted to pressure 

testing. 

(2)  The degree of compliance with the Provision and Use of Work Equipment 

Regulations 1998 (PUWER) and guidance issued by the HSE such as GS4 was 
called into question, not only at AGD but more widely within the industry. 
Witnesses gave evidence that the poor practices followed at AGD were 
replicated elsewhere. 

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 6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and your 
organisation have the power to take such action. The particular circumstances which led 
to Mr Seward’s death are unlikely to recur at AGD because pressure testing is now sent 
off-site. However, my concerns relate more widely and include the proper understanding 
of pressure testing and the safe management of associated risks across the industry. 
Your organisation appears to be well-placed to assist with raising awareness of these 
concerns.  

The action I am asking of you should include an explanation of the steps you are taking 
to raise awareness of the risks associated with pressure testing, and of how companies 
and individuals can gain access to guidance from the HSE. 

I have written separately to the Managing Director of AGD. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 31 May 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 Mr Seward’s family and legal 
representatives. I have also sent a copy to 
 HM Inspector of Health and 
Safety. I am aware that 

has recently visited AGD.  

I am 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 

DATE of REPORT 

5 April 2016                                                        David Clark, Assistant Coroner  

2

AGD Equipment Limited

Avonbrook House 198 Masons Road « Stratford Enterprise Park
Stratford-upon-Avon * Warwickshire * CV37 9LQ « United Kingdom

t: +44(0)1789 292227 f: +44(0)1789 268350 info@agd-equipment.co.uk www.agd-equipment.co.uk

Response Report

This report has been prepared in response to the Regulation 28 Report to prevent future

deaths dated 5" April 2016 from David Clark Assistant Coroner.

Please find below a detailed list of actions taken by AGD Equipment Limited since 27" May 2015

together with those that are work-in-progress at the present time.

The company has a health and safety policy setting out the roles and responsibilities for
all personnel including directors, managers and employees. A copy of this policy is
available both electronically on the computer and in a hard copy kept in the office, which
is accessible to all employees. A further copy of the policy is displayed on the health and
safety notice board by the canteen and another copy is on display in the office reception

area.

Following the Inquest all staff have been reminded about the health and safety policy
and where it can be found. The AGD employees who gave evidence at the Inquest had
actually been involved in drafting the original policy and should therefore have been well

aware of its contents.

AGD continue to use the Site Safety PowerPoint induction given to all staff before they
start work. Following the Inquest, AGD have reviewed the induction with specialist advice
from the company’s health and safety consultants. The induction details the key health
and safety positions at the company and explains the health and safety hierarchy. All

staff are being given refresher training on these elements.

The company has a Health and Safety Committee with representatives from various
areas of the business, as well as a representative from the company’s health and safety
consultants. The Health and Safety Committee meet monthly to discuss on-going health
and safety issues. These health and safety meetings are fully minuted and the minutes
are sent to the Board of Directors. The minutes are reviewed during Board meetings
where health and safety is a top item on the Board Agenda. The Health and Safety
Committee has been in place for a long time but again refresher information has been

AGD Equipment Limited Directors: W.H.Law (Chairman) R.W.Law (Managing Director) E.A.Law
Registered office as above Registered in England Company number 01275753 A subsidiary of AGD Holdings Limited

RCSPA
Member

given to all staff to remind them of the existence of the Committee and its function. Work
is being underaken to ensure the Committee is a fully integrated and interactive part of

the safety culture in the company.

AGD are working closely with the HSE to ensure that risk assessments and safe systems
of work are in place. AGD are aiso working with the close assistance of the company’s
nealth and safety consultants throughout this process to identify all risks, work duties and

equipment, to ensure nothing is overlooked.

Following the accident on 27" May 2015 the company reviewed all risk assessments,
COSHH assessments and safe systems of work. AGD's health and safety consultants
were involved in this process and the Supervisory Team must access and use these

documents when planning new tasks, or allocating work to personnel.

Having drawn up individual safe systems of work, toolbox talks were delivered to all
employees likely to be involved in the relevant tasks to ensure that they understood the
task and the controls in place to work safely. A full record is kept of these toolbox talks,
and they continue to be discussed by the Health and Safety Committee at monthly

meetings to ensure a rolling programme of continuous improvement.

The company health and safety documents including the policy, risk assessments and
safe systems of work aiong with relevant HSE Guidance are held electronically on
servers and computers. The company has also given the mobile engineers electronic
tablets containing these documents for off-site reference. A hard copy of all electronic
documents is also held in folders located in the Service Department office. This was
already the case at the time of the Inquest and was within knowledge of those employees
who gave evidence because they were part of the team directly involved in putting the
documentation together. It is nat known why this information was not given to the Coroner
at the Inquest. Refresher training and awareness raising has been rolled out across all
employees to remind them where ail health and safety documents can be found.

The company continue to use and update the comprehensive training matrix of skills and
competencies for all employees. This matrix details all health and safety training
provided, or arranged by AGD, and is reviewed regularly at the Health and Safety
Committee meetings. Full minutes of the Heaith and Safety Committee meetings are not
only passed to the Board but are also displayed on the health and safety notice board.

The company is undertaking a full review of its safety management system to ensure
that robust arrangements are in place for the future which covers (1) the company
philosophy on safety; (2) the arrangements in place to plan and supervise work properly;

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(3) the arrangements in place to ensure all staff are skilled, trained and competent for
the work they undertake; and (4) to ensure the monitoring arrangements are adequate
and properly undertaken. Hand in hand with this review is a new communications
strategy to ensure all staff are aware of the system, its rules and their own

responsibilities.

AGD have appointed a new Safety Officer/Assistant Manager with substantial
experience in operational workshop health and safety. This new role has been recruited
to ensure that working practices are up-to-date with current legislation and industry best
practice. To compliment this new role, the company has altered the Paint Shop
Supervisor role to the wider role of Workshops Supervisor so that the new Safety
Officer/Assistant Manager can concentrate on ensuring all health and safety rules,
controls and best practices are understood and fully implemented throughout the

operational site for all employees and visiting suppliers.

The company continue to outsource all pressure testing work and have no intention of

ever bringing the work back in house.

A new traffic management plan has been introduced and fully implemented to improve
safety in regards to all vehicle movements in and out of our facility.

AGD have invested in a new health and safety software called Cognitia Safety and
Compliance, which enables the company to manage all the health and safety
documentation in one place. The software holds all the risk assessments, safe systems
of work, COSHH assessments, near miss/accident statistics, training certificates and
occupational health medical certificates. The software will be continually updated with
the latest documents and certificates. The office employees are currently receiving
training on this software so that they are able to use and refer to it on a daily basis.

Over the past twelve months AGD have spent in excess of £110,000 on safety, welfare
and training. The company always have and always will invest in anything necessary to
further ensure the safety of all employees, irrespective of any budget in place.

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