Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0324, written 28 Sep 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Sep 2018 |
|---|---|
| Reference | 2018-0324 |
| Deceased | Donald Berry |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Business, Acting Chief Executive for HSE and Director of Kendal Calling CORONER | am Alison Mutch ,Senior Coroner, for the coroner area of South Manchester CORONER'S LEGAL POWERS 1 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 24" August 2016 | commenced an investigation into the death of Donald Peter Berry. The jury inquest concluded on the 6"" September 2018 and the conclusion of the jury was one of accidental death The medical cause of death was: 1aBronchopneumonia; 1bRecurrentChest Infections; 1c Immobility due to paralysis ll Epilepsy due to traumatic brain injury caused by electrocution 4 | Donald Berry suffered severe injuries due to being electrocuted whilst working at the Kendal Calling Festival on 22 July 2010. These injuries resulted in ongoing health complications leading to his death on 23” | August 2016 at St Mark’s Care Centre 28 Delaunays Road, Sale. 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. — 1.The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority. 2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law for licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC's area for large events such as 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 23rd November 2018. |, 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 namely fe of Donald Berry, 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 response, about the release or the publication of your response by the Chief Coroner. Alison Mutch OBE HM Senior Coroner 28" September 2018
3 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.
AG Kelly Tolhurst MP REC E IVE D a seabed Business, Energy & Industrial Strategy Department for + NOV 2018 CH 1 Victoria Street Business, Energy London & Industrial Strategy | -------=*------ SW1H OET T +44 (0) 20 7215 5000 E enquiries@beis.gov.uk Alison Mutch OBE W www.gov.uk HM Senior Coroner Coroner's Court 4 Mount Tabor Street esi S| November 2018 SK1 3AG Lownie maton. Thank you for your letter and Regulation 28 Report to Prevent Future Deaths, dated 28 September 2018, following your investigation and inquest into the death of Mr Donald Peter Berry on 23 August 2016, who died due to injuries and subsequent ongoing health complications from an accidental electrocution by a high voltage power line whilst working at the Kendal Calling Festival. | am responding as the Minister responsible for Product Safety Policy. | would first like to say how sorry | was to hear about this grievous incident. If you have the opportunity, please convey my deepest sympathies to Mr Berry's family. | note that in your report you identify that the organisers of the event did not properly consider the health and safety risk of high voltage electrical installation at the place of the event. This is not an issue relating to the safety of an electrical appliance, which would fall within my Department's remit. As this is a health and safety at work issue, it falls within the remit of the Health and Safety Executive (HSE), who are sponsored by the Department for Work and Pensions. | note you have sent this notice to the Acting Chief Executive of the HSE. My Officials have contacted the Principal Inspector at the Health and Safety Executive (HSE) to inform him of your letter. | understand that the Principal Inspector will be responding shortly. if you would like to get in contact with him directly, his details are as follows: HM Principal Inspector of Health and Safety Entertainment, Leisure, Commercial and Consumer Sector Health and Safety Executive 19 Ridgeway 9 Quinton Business Park Quinton BIRMINGHAM B32 1AL Tel: 0203 028 1713 Yours sincerely KELLY TOL ST MP Minister for Small Business, Consumers & Corporate Responsibility
Health and Safety Executive Engagement & Policy Ms A Mutch OBE Division HM Senior Coroner Manchester South Coroner's Office Coroner’s Court Local Authority & Safety RECEIVED 1 Mount Tabor Street Unit Stockport IOV 2618 19 Ridgway SK1 3AG 22 N P 9 Quniton Business Park _ saan Birmingham B32 1AL Tel: 0203 028 1713 http:/Avww.hse.gov.uk/ Head of Unit ll Reference: Your reference: 5199/CH Date: 12 November 2018 Dear Ms Mutch Prevention of future deaths report — Donald Peter Berry Date of death 23 August 2016 Inquest at Manchester South Coroner's Court on 24 August - 8 September 2018 | am responding to your Regulation 28, Prevention of Future Deaths report addressed toll cting Chief Executive of the HSE that arises from your inquest into the death of Mr Berry. Your report was passed to me as head of the team with responsibility for national health and safety policy for the entertainment and leisure sector. You raised concerns as to high voltage overhead power lines not being identified as a hazard by the event organisers, nor relevant other parties, which resulted in the incident that ultimately led to Mr Berry's death. Event organisers, in common with other employers, have responsibilities under the Health and Safety at Work etc. Act 1974 to ensure, so far as is reasonably practicable, the health, safety and welfare of their employees. Event planners and organisers must consider the risks to these employees and take reasonably practicable steps to control those risks throughout the whole process, from set-up to take-down. Proper planning and organisation of such events should include consulting and acting upon the guidance and advice provided by HSE and by industry bodies. HSE has published web-based event safety guidance to help event organisers comply with their legal duties — see _http://www.hse.gov.uk/event-safety/index.htm The guidance helps organisers identify risks, such as those arising from contact with overhead high voltage power lines In addition, and referred to in your report, the industry produced guidance ‘Purple Book' covers a wide range of legislative requirements that event organisers need to take into account, including workplace health and safety law The ‘Purple Book’ has a section on electrical safety which includes reference to the importance of organisers identifying existing overhead power lines to ensure that controls are put in place to ensure the safety of those working beneath those lines. HSE leads on national occupational health and safety policy for the entertainments and leisure sector, whilst Local Authorities are responsible for enforcing the law at individual events in their geographical area. In this case, Eden Council successfully prosecuted the event organisers for breaches of the Health and Safety at Work etc. Act 1974 in March 2013. | consider that the current available guidance enables event organisers and other relevant persons and bodies to identify the risks arising from overhead power lines. | will however take the opportunity to raise awareness of this incident with industry stakeholders, underlining the importance of all people involved in event organising and planning to adhere to the standards set out in guidance. Yours sincerely A HM Principal Inspector of Health and Safety
Ben Robinson iol 489 Didsbury Road Stockpon eSk4 83BY © Phone: 07966691656 © E-Mail: ben 4 fiomthelields.conk RECEIVED ~ § NOV 2018 CH co Date: 5" November 2018 Alison Mutch OBE Coroner Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch, Thank you for your letter dated 28* September regarding the inquest into the death of Mr Berry. Following your request for further information on what changes have been made to the operations of our business to help prevent future incidents I enclose a letter ioi<_— is the current Health and Safety advisor for Kendal Calling who works on behalf of event production company Ground Control. Ground Control were appointed the season following the incident to undertake all safety and event management activity for Kendal Calling. They are industry leading professionals and have a joined up approach on safety and event production. I hope this information is sufficient for the request. If you require any further information please contact me on the details at the header of this letter. Sincerely, oe Director Kendal Calling.
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