Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0107, written 17 Apr 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Apr 2018 |
|---|---|
| Reference | 2018-0107 |
| Deceased | Matthew Wilmot |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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for Bedfordshire & Luton REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 42934-2017 THIS REPORT IS BEING SENT TO: | friends. A friend travelled back with him by taxi, dropping him off near his home | | | M&S Water Services (Utilities) Limited B&D Civil Engineering Limited Unit 6 | Ghost Barn High Town Enterprise Centre Hoo Farm | I | York Street | High Street | | Luton | Hitchin | Bedfordshire Herts : | LU2 OHA SG5 3ED / i (1 | CORONER i | Lam, lan Pears, Acting Senior Coroner for Bedfordshire & Luton | 2 | CORONER’S LEGAL POWERS i | | make this report under paragraph 7, Schedule 5, of the Coroners and Justice i ; Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations ! 2013. | http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www legislation.gov.uk/uksi/2013/1629/part/7/made | (3 | INVESTIGATION and INQUEST | | On 1June 2017 | commenced an Investigation into the death of Matthew James | | WILMOT aged 40 years. The Investigation concluded at the end of the Inquest | /on 12 April 2018. The conclusion of the Inquest was ‘Accidental Death’. The | medical cause of death was: | (a) High blood ethanol concentration consistent with i significant intoxication together with fatal hypoxia i L 4 CIRCUMSTANCES OF THE DEATH ! | | i The deceased went out for the afternoon/evening to watch the FA Cup Final with bi nee Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX ‘Tel 0300-300-6559 | Fax 300-300-8267 at 00.45 hours on 28 May 2017. At 07:14 hours a call was made to the Ambulance Control from the resident of 280 Devon Road, Luton, Bedfordshire, stating that the deceased was upside down in a hole outside her house. | secured to the metal fence. A risk assessment had taken place. | given to the nature of the path. To all intents and purposes there are two types of paths. The most common is | iis no road to the side. This particular path lead from the road to a row of | The path was not located in an area of risk. 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 : The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing a sign at each end of the path stating that the path was closed. The hole and spoil were fenced off by using a metal railed fence which was alongside the path and 4 plastic yellow barriers which were The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality, footfall, etcetera. My concern is that not enough consideration was the path that runs parallel to a highway. If that path is closed, the pedestrian can be guided around the excavation or told to cross the road. It is unlikely that the pedestrian would walk through a barriered area in such circumstances as that would be slower than walking around it. The second type of path is one that is unique in its journey from A to B, ie there houses, which were not accessible by road. The alternative route (which was not signposted) was 150 metres away, meaning a diversion of about 300 metres. However, my concern is that a route that is unique is always at risk as pedestrians will want to travel the shortest route. This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the 7 hours before the deceased was found. The excavators took photographs of the site just before they left it. Looking at those photographs, | would have risked waiking down the closed path. My concern is that there is not enough emphasis within the risk assessment | process that a route that is unique has different risks to a path that is parallel. Senior Coroner, The Court House, Woburn Street. AMPTHILL, Bedfordshire, MK45 2HIX. Tel 0300-300-6559 | Fax 0300-300-8267 . 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 29 June 2048. |, 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. i "COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ; e Amey Utility Services Limited i e Affinity Water Limited | e The Department of Transport | e BE 02" of the deceased) | | 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 17 April 2018 | | JAN PEARS | Acting Senior Coroner | _ for Bedfordshire & Luton Senior Coroner, The Court House. Woburn Street, AMPTHILL. Bedfordshire. MK45 2HX Tel 0300-300-6559 | Fax 0300-300-8267
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.
HM Coroner for Bedfordshire & Luton Our ref: 1PDP-EV1007-70818 The Court House Your ref: 42934-2017 Woburn Street Date: 28 June 2018 Ampthill Bedfordshire MK45 2HX fe Dear Sirs Our client: B & D Civil Engineering Limited Deceased: Mr Matthew James Wilmot Date of incident: 28 May 2017 We write on behalf of our client, B & D Civil Engineering Limited in response to the Regulation 28 Report dated 17 April 2018. We note the concern is that there was not enough emphasis within the risk assessment process that a route that does not run parallel to a highway has different risks to a path that is parallel to a highway. It is further noted that the Coroner was satisfied that the evidence given at Inquest was that the risk assessment undertaken in connection to the excavation outside 280 Devon Road was in line with the Red Book and Industry Standards and the path was not located in an area of risk. During the course of the Inquest, evidence was heard in respect of the contract/responsibility matrix including evidence that B & D provided labour, plant and equipment pursuant to a subcontract. The Inquest considered the relevant risk assessment and method statement. In addition, evidence was heard in relation to exhibit TH2, a Team Briefing given following the accident involving Mr Wilmot. The Briefing followed a review of the risk to the general public regarding open excavations and it briefed attendees to take into consideration certain specifics before leaving an open hole. The specifics together with the proposed steps to be taken are recorded in the copy Briefing annexed hereto. The Briefing attended by B & D operatives emphasised focus on risks connected to an open hole and the likelihood of the public using an alternative route. It will be appreciated that on the Devon Road site the operatives were required to complete the Amey Utility Services Limited risk assessment template. ect p rnior standing and includes non-solicivorsand edor an employee or consultant at equiv dat wwwilawseotorgutk n 511g} whose professional mules can Our client is advised that in order to address the specific concern of the Coroner M & S will amend point 4 of the Briefing to read, “if a footway closure/road closure/alternative pedestrian route is setup, is it suitable/will pedestrians follow it? If the assessment is that they will not, please contact your supervisor for advice”. The procedure enables operatives to escalate any concerns for the supervisor to make the final decision on the appropriate control measures to be put in place. Our client is advised the revised Briefing will be a mandatory part of the induction process for any new operatives supplied by B & D and existing operatives will be briefed and refreshed at six-month intervals. Yours faithful ' yar li Plexus Law Plexus and Plexus Law aes lr! of egu S No. 519) whose professional rule
silyl WWW. mandswaterco uk Your Ref: 42934-2017 28 June 2018 HM Coroner for Bedfordshire & Luton The Court House Woburn Street Ampthill Bedfordshire MK45 2HX Dear Sirs Deceased : Matthew James Wilmot Date of Incident : 28 May 2017 We write in response to the Regulation 28 Report dated 17 April 2018. We note the concern is that there was not enough emphasis within the risk assessment process that a unique route has different risks to a path that is parallel. itis further noted that the Coroner was satisfied that the evidence given at the Inquest was that the risk assessment undertaken by M&S for the excavation outside 280 Devon Road was in line with the Red Book and Industry Standards. During the course of the Inquest evidence was given in relation to exhibit 'TH2’. The document was the Team Briefing given following the accident involving Mr Wilmot. The briefing followed a review of the risk to the general public regarding open excavations. It stated: Please take into consideration the following specifics before leaving an open hole:- 1. Would you expect high footfall in the area e.g.: school, public house, hospital, GP Surgery 2. Is the job likely to be ongoing e.g.: due to Engineering difficulties 3. Have you any reason to suspect that a MOP might move our barriers, take into consideration surrounding houses ete. 4. If you have to provide the public with an alternative route is it realistic and easy to negotiate? We must be compliant but we must also be realistic in our expectations. & ae Gatek CHAS Q Assured “soma” Constructionline |. Reeitered Fores ASOT LU2 DHA 1 Unii 6, High Towa Enterprise os ecretary: KM Harkin | Centre, York Street, Luton, Bedfards Director: MJ, Markin: Direstor & Co. eg. if any of the above is a concern then please consider all or some of the following: 1. Consider storing the spoil elsewhere to enable us to keep the footpath open 2. Consider plating fhe excavation 3. Consider the need for Heras Fencing if you need advice then contact your supervisor. It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S Operatives were required to complete the Amey Utility Services Limited risk assessment template. Given that no two sites are the same, the Company is wary of being too prescriptive in respect of the guidance given to operatives. Therefore, in order to address the specific concern of the Coroner the Company has amended point 4 of the briefing to read as follows:- 4. If a footway closure / road closure / alternative pedestrian route is setup, is it suitable / will pedestrians follow it? If the assessment is that they will not, please contact your supervisor for advice. The intent is to provide a procedure for operatives to escalate any concerns in relation to ‘unique’ locations to a supervisor and for the supervisor to then make the final decision on the appropriate control measures to be put in place. As such, the procedure will ensure supervisory involvement in relation to assessments of all ‘unique’ locations. The briefing will be a mandatory part of the induction process for any new operatives and will be refreshed for all existing operatives at six month intervals. It is important to stress that M&S does not fulfil the role of the Job Initiator or Job Planner. The evidence of Amey (paragraph 4.5 of statement dated 14° December 2017) was that the Job Planner reviews the job for any special requirements based on the Job Initiator’s comments. The process involves a visit to the site by the Customer Services Technician. To this extent there is also the opportunity within the planning / permitting process to identify any ‘unique’ locations. As was highlighted during the Inquest hearing, the Company is committed to going above and beyond existing Industry Standards / guidance in relation to Street Works. The additional processes now put in place are part of the commitment to continuous improvement. Yours faithfully M&S Water Services (Utilities) Ltd
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