Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0027, written 1 Feb 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Feb 2018 |
|---|---|
| Reference | 2018-0027 |
| Deceased | David Green |
| Coroner | Caroline Beasley-Murray |
| Coroner area | Essex |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
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:-
Rose Builders and Contractors Ltd
Riverside House, Riverside Avenue East
Lawford, Manningtree
Essex CO11 1US
1
CORONER
I am Caroline Beasley-Murray, senior coroner, for the coroner area of Essex
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 12 October 2016 I commenced an investigation into the death of David Scott Green.
The investigation concluded at the end of the inquest on 13 March 2017. The conclusion
of the inquest was:-
David Scott Green died as a result of an accident
4
CIRCUMSTANCES OF THE DEATH
David Green, who was 32 years old at the time of his death was driving a dumper truck
at Coxs Hill Lawford, Manningtree, Essex on the 3 October 2016 over a mound of earth.
The ground gave way and the vehicle toppled forward over the edge. His seat belt was
not in use and he ended up underneath the vehicle.
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. –
There did not appear to be a safe system of work in operation on the site.
There seemed to be a widespread practice of employees not wearing the seat
belts provided with the vehicles.
There seemed to be an inadequate system of checking whether or not
employees were wearing seatbelts in the course of their work.
Cont…..
1
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.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 working days of the date of this
report, namely by 19th April 2018. 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 – Hutcheon Law , solicitors for the family
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
[DATE] 01 February 2018 Caroline Beasley-Murray
2
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.