Prevention of Future Deaths reports · 2016

Matthew Gunn

Regulation 28 report to prevent future deaths, reference 2016-0217, written 9 Jun 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Jun 2016
Reference2016-0217
DeceasedMatthew Gunn
CoronerKaty Skerrett
Coroner areaGloucestershire
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.

H M Senior Coroner for Gloucestershire
Ms Katy Skerrett

Fax:

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:
(1) Chief Executive of W M Morrison Plc, FAO Bs ou Head of Health and
Safety, and DWF LLP (fao: FY 20 Fenchurch Street, London EC3M 4AG

CORONER

| am Katy Skerrett, Senior Coroner for Gloucestershire.

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.

INVESTIGATION and INQUEST

On the 15" October 2014 | commenced an investigation into the death of Matthew Joseph Gunn.
The investigation concluded at the end of the jury inquest on the 23” May 2016. The conclusion
of the jury was accidental death and a narrative conclusion. The medical cause of death was 1A
traumatic head injury.

CIRCUMSTANCES OF THE DEATH

At approximately 14.30 hours on the 25" September 2014, Matthew Joseph Gunn fell from
height whilst using the staff staircase at Morrison’s supermarket, Ashchurch road, Tewkesbury
GL20 8BN. The jury found that Matthew’ S fall was probably caused by an epileptic event, and he
subsequently died in hospital on the 7" October 2014 from the injuries he sustained in the fall.

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) Any observed or reported epileptic event occurring to a Morrison’s employee whilst at

work was not recorded

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
4pm 4" August 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.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested Persons,
(1) EE c/o Simon Bum Solicitors, 51 Promenade, Cheltenham,

Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ
Tel 01452 305661 | Fax 01452 412618

Gloucestershire GL50 1PJ, and
(2) Borough Solicitor, One Legal, Tewkesbury Borough Council, Gloucester Road,
Tewkesbury GL20 5TT.

| 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.

Dated 9th June 2016.

Signature

Ms K Skerrett
Senior Coroner for Gloucestershire

Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ
Tel 01452 305661 | Fax 01452 412618

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 Morrisons (PDF)
Morrisons

HM Senior Coroner for Gloucestershire
Ms Katy Skerrett

By email only

Dear HM Senior Coroner

Matt Gunn
Prevention of Future Deaths

| write in response to the Prevention of Future Death report (“PFD report”) under Regulation 28
received from you on 9 June 2016 and which requires Wm Morrison Supermarkets PLC
(“Morrisons”) to respond within 56 days detailing the action taken or to be taken whether in
response to the report or otherwise.

The PFD report indicates that the matter of concern was that:

“Any observed or reported epileptic event occurring to a Morrisons' employee whilst at
work was not recorded.”

You are of the opinion that this gives rise to a risk of future deaths.

As Morrisons understands, the suggested purpose of recording any observed or reported epileptic
event is so that it has information that may be of assistance to assess an employee’s epilepsy with
respect to their work as necessary. As the evidence clearly reflected at the inquest, it is important
to recognise that in order for Morrisons to have a full and accurate picture of an employee’s
epilepsy, it would be necessary for it to be informed by the employee of epileptic events that
occurred outside of work, for example, at home. It is only possible for Morrisons to record and act
on the epileptic events that it is informed of.

Therefore, it follows that the information recorded at the store about observed or reported
epileptic events will inevitably only be a partial picture given that there will be other episodes that
take place outside of work that Morrisons will be unaware of unless the employee chooses to
volunteer that information, which the employee is unlikely to do unless it affects their attendance
at work. As you are aware, and indeed the evidence at the Inquest reflected, in dealing with an
employee with epilepsy, or indeed any other disability, equality legislation would prohibit
Morrisons from requiring the employee to disclose the information.

Where an epileptic event occurs in store, then the process is as follows. The first stage after an
epileptic episode occurring is for a first aider to attend. If the epileptic event resulted in an
accident or was reportable under RIDDOR then it would be recorded in the accident book and/or
reported to the local authority or HSE. Where it does not, then the record of first aid attendance
and treatment given should be given to the People Manager and kept in the personnel file for the

Wm Morrison Supermarkets Plc Telephone; +44 (0)845 611 5000
Registered office: www.morrisons.co.uk

Hilmore House, Gain Lane,

Bradford, West Yorkshire 8D3 7DL

Registered in England no. 358949

member of the store team the People Manager reviews all first aid records and determines if
there was a trigger for an occupational health assessment for the employee.

In light of your concern, Morrisons has taken the opportunity to refresh this procedure in order to
re-emphasise the expected approach. Asa result, Morrisons is implementing:

(a) A bulletin will be sent to all stores instructing them to brief all employees to remind
them that any employee who has observed an epileptic event of an employee
should contact a first aider regardless of the nature of that event whether it is an
epileptic event or a temporary absence;

(b) An update to the first aid training and the first aid policy to remind of

(i) The need to complete a first aid slip for every call attended even if there is
no treatment given;

(ii) Where a first aider is not present, appointed persons will be instructed to
complete a first aid slip;

(iii) That all first aid slips must be reviewed by the People Manager and held on
file - this will be trained out to all People Manager’s.

(c) Where the epileptic event is reported via the return to work procedures this will be
recorded on the employee’s file and a reminder included of the need to review the
risk assessment for the individual and refer them to Occupational Health for
Assessment, if necessary.

For the avoidance of doubt, this procedure was in place at the time of Matt’s death but Morrisons
has reviewed and will re-emphasise as set out above key aspects to its employees. The bulletin is
anticipated to be issued by the end of August 2016 and the amendments to the first aid training,
and policy and the return to work procedures will be issued, and trained out completely by the
end of December 2016.

Yours faithfully,

Group General Counsel and Company Secretary

a
Wm Morrison Supermarkets Pic Telephone: +44 (0)845 611 5000
Registered office: www.morrisons.co.uk
Hilmore House, Gain Lane,
Bradford, West Yorkshire BD3 7DL
Registered in England no. 358949

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