Prevention of Future Deaths reports · 2018

James McLaren

Regulation 28 report to prevent future deaths, reference 2018-0330, written 4 Oct 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Oct 2018
Reference2018-0330
DeceasedJames McLaren
CoronerAndrew Hetherington
Coroner areaSunderland
CategoryOther related deaths
Sourcejudiciary.uk record · original PDF
Responses published4

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.

Derek Winter DL
Senior Coroner for the City of Sunderland

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: -

e The Local Government Association (LGA)

e The Environmental Services Association (ESA)

e Chartered Institute of Wastes Management (CIWM)
e The Health and Safety Executive (HSE)

CORONER

1 am Andrew Hetherington, Assistant Coroner for the City of Sunderland

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.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1629/part/7/made

INVESTIGATION and INQUEST

On 27th December 2017 an Investigation commenced into the death of James Ryan McLaren,
which concluded at the end of the Inquest on 3rd October 2018. The jury returned a conclusion
of Accident.
The Cause of Death, following Post-Mortem Examination, was: -

Ia Head and chest injuries

CIRCUMSTANCES OF THE DEATH

James Ryan McLaren was last seen leaving the Arizona Nightclub in Sunderland at 3:00am on
Saturday 23rd December 2017: CCTV footage shows James walking in the direction of Vine
Place at approximately 4:30am. The information from friends was that he previously climbed
into bins, when intoxicated, to sleep.

Max Recycle are a private collector of trade waste, covering a number of areas including
Wearside. The refuse collection vehicle arrived in Sunderland city centre at approximately
4:35am to collect mixed waste on 23rd December 2017. The bins, used by the customers on
Vine Place, are 1100 litre capacity, some of which have lids, but they are not usually locked.
Nothing was noted as a concern about the bin collections. Customers were still placing
material in the bins at that time of day. | also heard that an Operator used a head torch to
provide additional light.

Civic Centre, Burdon Road,Sunderland, SR2 7DN
Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland
www.sunderland.gov.uk/coroner

The last collection was at 5:30am and the refuse collection vehicle returned to the Hawthorne
Site. James was reported missing to the Police, and his mobile phone was tracked to the last
location in the area around Sedgeletch Industrial Estate.

Police together with a representative of Max Recycle located James’ body - James was found
deceased at the site of Max Recycling in Sedgeletch Industrial Estate at around 21:00hrs on
24th December 2017.

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 WISH WASTE 25 — Managing access to large waste and recycling bins — contains formal
guidance to prevent death or serious injury when people shelter in large commercial or
communal domestic bins. This guidance was provided to the Inquest. Factors increasing the
foreseeability of people gaining access and getting into the bins include, but are not limited to:

® the bin storage area:
e being quiet and isolated;
e being dark and unlit, especially at collection times;

"the bins:
e having lids that are not secured and easy to open.

I heard evidence that not all bins had lids, and that those, that did, had not been locked on 23rd
December 2017. I heard that where there were locks to the bins and their lids, some had a
generic lock that could be opened using a generic key, and that to unlock the bins would only
take a matter of seconds, and that this would not be an onerous task for an operator to unlock
the bin. I also heard that, although not in the location where James climbed into the bin, some
customers fitted combination locks to bins with a code shared on a manifest for the collection
vehicle. It is not known whether, once a bin is locked, it can be opened from the inside, and
this is also a concern. This is particularly relevant with the nights becoming colder and darker,
and the potential for people to seek refuge in bins due to the elements or for any other reason. |
raise this for your attention as to whether further steps can be taken to safely secure a bin and
deter entry therein.

For LGA: The Sunderland City Council Environmental Health Officers locally have sought to
raise awareness of the issue when conducting inspections of premises and customers using
bins. Could you raise awareness nationally of the issue to prevent death or serious injury
arising from access to large commercial or communal domestic bins?

For ESA: Could you raise your members’ awareness nationally of the issue and risk, and to
provide a reminder to employers and employees to consider a heightened check to look for
people who may be sheltering in the bins particularly in colder months? Would you consider
suggesting that head torches are used in dark or poorly lit areas regularly to provide additional
lighting which appears to be good practice?

For CIWM: Could you raise your members’ awareness nationally of the issue and risk, and to
provide a reminder to employers and employees to consider a heightened check to look for
people who may be sheltering in the bins particularly in colder months? Would you consider

suggesting that head torches are used in dark or poorly lit areas regularly to provide additional
lighting which appears to be good practice?

For HSE: Please would you clarify what it means in the WISH WASTE 25 formal guidance
for bins to be secure, and whether this should include the securing of bin lids by way of a
generic lock that can also be opened from the inside to prevent someone from being trapped?

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I 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 3" December 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.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following: -
e Family
e Max Recycle and their Solicitors
e Sunderland City Council Environmental Health Service

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.

Dated this 4" day of October 2018

Signature { : Ci cineonr

Assistant Coroner for the City of Sunderland

Responses

4 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.

Response from Ciwm (PDF)
7-9 St Peter’s Gardens,  
Marefair, Northampton, NN1 1SX  
United Kingdom 

T:  +44 (0) 1604 620426    
F:  +44 (0) 1604 621339  
E:   ciwm@ciwm.co.uk  
W:  www.ciwm.co.uk 

30th November 2018 

For the attention of Andrew Hetherington,  
Assistant Coroner for the City of Sunderland,  
Civic Centre,  
Burdon Road,  
Sunderland 
SR2 7DN 

Dear Sir 

We write in response to the Regulation 28 Report to prevent future deaths as a result of the 
investigation  into  the  death  of  James  Ryan  McLaren.   Section  7  of  the  report  requires  that 
CIWM is under a duty to respond to the report within 56 days, namely by 3 December 2018 to 
contain details of action or proposed to be taken, setting out a timetable for action. 

The actions for CIWM were to raise members' awareness nationally of the issue and risk, and 
to provide a reminder to employers and employees to consider a heightened check to look 
for people who may be sheltering in bins particularly in colder months. 

In 2014 CIWM in association with Biffa and Street Link produced a report 'Research into the 
issues, risks and prevention of people sleeping in bins'  

https://wlfu3o6m8a45atds1tysz915-wpengine.netdna-ssl.com/wp-
content/uploads/2015/05/Streetlink_CIWM_Biffa-Research-Report-Final_Feb14.pdf 

This report promotes the use of the WISH guidance document WASTE25 which was published 
in  2010  and  is  still  relevant  today.   CIWM  fully  supports  the  work  of  WISH  and  is  an  active 
member  of  the  organisation.  CIWM  and  the  other  organisations  involved  in  the  report  and 
the  guidance  document  continue  to  promote  their  operational  use  as  they  remain  as 
relevant now as when they were published.  

Over  the  past  few  years,  there  have  been  a  number  of  campaigns  by  waste  collection 
companies such as the B&M and Shelter 'Refuse not Refuge' annual winter campaign which 
launched in  2013  and  publications  such  as  Skip  Hire  magazine  and  The  Big  Issue  'Whack  a 
Bin' campaign in 2015.  These campaigns, undertaken by individual operators in association 
with  homeless  charities,  have  been  promoted  to  CIWM  members  via  the  weekly  member 
newsletter  and  social  media.   This  year  CIWM  published  a  press  statement  which  was 
circulated to members to show support of the B&M campaign and to also highlight the use 
of WASTE25 guidance to waste producers. 

https://www.ciwm.co.uk/ciwm/news/2018/ciwm_welcomes_b_m_waste__refuse_not_refuge
__campaign.aspx 

A Company Incorporated by Royal Charter. Registered in England No. RC000777 A charity registered in England and Wales (1090968) and in 
Scotland (SCO37903). Registered Office: 7-9 St Peter’s Gardens, Marefair, Northampton, NN1 1SX. VAT Registered No. 232 8003 02. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In  2016  three  waste  management  companies  joined  forces  together  with  CIWM,  ESA  and 
HSE  to  pool  resources  to  share  information  and  create  industry  wide  initiatives  to  save  lives 
and formed the Steering Group ‘People in Bins’.  The intention of the Steering Group was to 
include  more  organisation  members  over  time  and  work  with  local  authorities  too.   This 
remains  the  aim  of  the  group,  however  there  are  difficulties  in  involving  as  many 
organisations as we would like.   

Under  the  Health  and  Safety  campaign  'This  time  it's  personal'  umbrella,  CIWM  are  in  the 
process  of  restarting  the  ‘People  in  Bins’  Steering  Group  with  the  original  members  and 
including LARAC and ROSPA; the objectives of the group will be to: 

-  help  to  share  the  WASTE25  guidance  document  more  widely  with  waste  producers  to 
ensure  the  contents  of  the  bins  are  being  checked  when  they  are  in  use  and  when 
collected  

- help people to be aware that large bins are not for sleeping in 

-  encourage  waste  companies  to  ensure  collection  crews  receive  training  to  check  large 
bins  before  they  are  emptied  being  particularly  vigilant  when  large  bins  are  stored  in  unlit 
areas  

- create a standard single page do's and don'ts document to encourage waste companies 
to  issue  this  to  their  customers  to  encourage  them  to  follow  WASTE25  guidance  to  ensure 
waste presented has been checked prior to collection and that the bin storage area is well 
maintained, has adequate lighting and that bins are locked over night  

- encourage waste companies to record incidents of intercepting people sheltering in bins to 
enable  data  to  be  gathered  on  common  locations;  times  of  year;  etc  to  enable  a  more 
detailed and targeted campaign in following years 

- encourage waste collection companies to share photographs of good and bad practice 
of  bin  storage  areas  so  that  waste  producers  can  improve  standards  of  bin  storage  areas 
thereby making the bins inaccessible to public access 

-  CIWM  would  like  to  undertake  an  update  to  the 2014  report  to  see  how  the  situation  has 
changed since this date. 

A  telephone  meeting  took  place  involving  HSE,  LARAC,  ROSPA,  WISH,  CIWM,  Hart  District 
Council, O’Donovan Waste Disposal Ltd, Coastal Recycling Limited and Biffa on 7 November 
to discuss the above objectives.  Since this date CIWM has produced imagery promoting the 
use of WASTE25 guidance and encourages waste producers and waste collectors to check 
the bins while filling and unloading.  These images have been and continue to be shared on 
Twitter and LinkedIn regularly. 

CIWM  will  aim  to  write  an  article  for  the  CIWM  journal  /  website  to  promote  the  ‘People  in 
Bins’  Steering  Group  and  call  for  volunteer  waste  collection  companies  to  get  involved  by 
providing data to mirror the 2014 report by February 2019. 

Yours faithfully 

 FCIWM, Chartered Waste Manager, CEnv 

Executive Director
Response from Esa (PDF)
CS environmental
services.
association

FROM THE EXECUTIVE DIRECTOR
Direct TEL 020 7591 3200

28 November 2018

Mr Andrew Hetherington

HM Assistant Coroner for the City of Sunderland
Civic Centre

Burdon Road

Room 2.108 Office of HM Coroner

Sunderland

SR2 7DN

Dear Mr Hetherington

Regulation 28 report

| write in response to the regulation 28 report into the tragic circumstances of the death of Mr
McLaren. ;

The Environmental Services Association (ESA) is the trade association for the waste and recycling
industry. We work with all levels of government, regulators and the public to deliver a more
sustainable approach to the management of the UK’s waste. Our Members provide a range of waste
management and collection services for both householders and businesses.

You direct two questions to ESA; | respond to each in turn below.

Could you raise your Members’ awareness nationally of the issue and risk, and to provide a
reminder to employers and employees to consider a heightened check to look for people who may
be sheltering in the bins particularly in the colder months?

The risks posed by people in waste containers has been high on ESA’s health and safety agenda since
about 2009 when this issue first emerged as a concern. Since then ESA has actively sought to raise
the profile and dangers posed by people in containers to ensure that awareness, and control
measures, are disseminated across the industry as widely as possible.

ESA has:

e used the national and trade press to communicate key messages;

e participated in a cross-sector steering group set up to reduce the risk of harm caused by
people in containers;

e arranged a ‘people in containers’ safety week;

e issued a safety alert to ESA Members; and

© contributed to the development of guidance, WISH Waste 25 (people in containers)

www.esauk.org
154 Buckingham Palace Road, London SW1iW 9TR
lel: 020 7824 8882 email: info@esauk.org

Jirornmental Services Association Ltd. A company limited by guarantee. Reg no 962961 London. VAT no 243 801k

With the onset of winter, we will re-issue a safety alert in December 2018 to our Members as per
your request and include a link to WISH Waste 25, which contains guidance on practical checks that
can be carried out by collection crews prior to uplift of containers.

Would you consider suggesting that head torches are used in dark or poorly lit areas regularly to
provide additional lighting which appears to be good practice?

The servicing of any waste collection contract requires an assessment of health and safety risks,
which includes an assessment of risks at the point of waste collection. Lighting conditions, along with
a host of other relevant factors, are considered as part of a waste contractor's risk assessment
process.

The risk assessment process will inform the course of action taken to address the risk and, in some
cases, the provision of head torches might very well be deemed appropriate. However, within the
hierarchy of control there could be other more effective measures than head torches in addressing
the specific risks presented at any given site. For example, the provision of LED lighting at the rear of
a collection vehicle (where it was not possible to orientate the vehicle to make use of its headlamps)
would help to illuminate the working area far more effectively than a head torch. Furthermore,
other checks (as detailed in section 6 of WISH Waste 25) are likely to be just as effective in
preventing harm.

In practice, some ESA Members use head torches, others deploy alternative measures informed by a
thorough risk assessment process. Head torches might be issued in one part of the business and not
in another, where risk was assessed to be much lower. Rather than endorse a ‘one size fits all’
approach, of key significance is that the selected approach is effective, can be justified and is
proportionate to the risk,

An often overlooked aspect is that the hierarchy of control referred to above is of equal
consideration to waste producers (those businesses responsible for placing waste into a container)
who, as waste holders, have a duty to prevent risk of harm to the public. The storage of waste
containers in a secure and well-lit area is considered (among other measures) as a reasonable
practical step towards meeting this duty, and would be likely to help discourage people from seeking
refuge in containers in the first place.

ESA and its Members strongly advocate the approach adopted in the WISH Waste 25 guidance and
aim to ensure that this is kept up to date to reflect new techniques or the safest working practices. It
is also incumbent on the industry, working in collaboration with HSE and others to raise awareness
of the vital part waste producers have in helping to keep people safe, and the practical steps that
can be taken on site towards this aim.

Yours sincerely,
Response from Hse (PDF)
Health and Safety 

   Executive 

Engagement & Policy Division 

Head of Vulnerable Workers, 
Agriculture Waste & Recycling 
Unit 
Kingsley Dunham Centre 
Nicker Hill 
Keyworth 
NOTTINGHAM 
NG12 5GG 

Tel: 0203 028 2794 
Fax:  

http://www.hse.gov.uk/ 

Head of Division 

Mr A Hetherington 
Assistant Coroner for the City of Sunderland 
Civic Centre 
Burdon Road 
Sunderland 
SR2 7DN 

Date:  8 November 2018 

Dear Mr Hetherington  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – JAMES RYAN MCLAREN  

Thank you for your Regulation 28 Report issued following the death of James Ryan McLaren.  I would 
like to convey HSE’s sincere condolences to James’s family.  In your report you raise a number of 
questions with the LGA, ESA, CIWM and HSE.  In particular you have asked HSE to “clarify what it 
means in the WISH WASTE 25 formal guidance for bins to be secure, and whether this should include 
the securing of bin lids by way of a generic lock that can also be opened from the inside to prevent 
someone from being trapped?” 

The Waste Industry Safety and Health Forum (WISH) is an industry led organisation that exists to 
communicate and consult with the waste and recycling industry to improve its health and safety 
performance.  The guidance WISH produces, such as WASTE 25, Manging Access to Large Waste and 
Recycling Bins, is developed by the industry and HSE is consulted on the content.  HSE are a member 
of, and advisor to, WISH but does not own the guidance that WISH produces. HSE does however 
endorse guidance produced by WISH as a means of managing risk, complying with the law and 
demonstrating best practice as industry standard. 

The legal requirements for managing access to large waste bins stems from the Health and Safety at 
Work etc Act and associated legislation.  The legislation is, in the main, outcome based and not 
prescriptive on how safe outcomes can be achieved.  In relation to large bins the legislation effectively 
requires those using such bins, and those collecting the contents, to assess risk to others and do what 
is reasonably practicable to manage that risk.  In the case of the risks covered by WASTE 25 this is in 
relation to the known issue of people taking shelter in large bins and the risk of subsequent injury or 
death when the bins are emptied into collection vehicles.   The law is not prescriptive and WASTE 25 
effectively demonstrates the risk and guides users to ways in which it can be managed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Recognising a growing trend of people being discovered in commercial bins and containers WASTE 25 
was developed to provide advice and guidance for businesses that produce commercial waste, manage 
a waste bin storage area, or collect waste as part of their work activity.  It sets out reasonable measures 
that can be taken to try and prevent people sheltering in bins to prevent the subsequent risk of injury 
during collection activities.  It also includes the steps collection operatives can take to check bins as it 
recognises that the steps to prevent access are not infallible.    

The guidance sets out circumstances that make it more likely that a person may try to gain access to 
bins taking account of location, the nature of materials collected in the bin, ease of access and so on.  
These are the factors that a business using such bins will need to take into account to decide what 
measures they need to adopt to restrict access.  Where it is reasonably foreseeable that someone may 
access a bin the legal obligation on a user is to do what is reasonably practicable to prevent access.  

WASTE 25 then sets the reasonable precautions that businesses can take to prevent non-employees 
(with the exception of collection crews) from freely accessing any bins, i.e. to keep the bin “secure”.  In 
this context security is taken to mean preventing a person physically getting into the bin. The guidance 
highlights factors that could increase the potential of persons accessing commercial bins and containers 
– such as leaving them in an open and/or unsecured area. Businesses should consider storing their 
bins within their building, within the curtilage of their premises, or in a dedicated secure area/enclosure.  
This in itself may be sufficient to prevent access and negates the needs for individual bins to be locked.  
Other deterrents such as locating bins in a well-lit area will have a role to play.  

If securing an area is not sufficient, or not practical, using lid locks to secure bin lids is another potential 
means of controlling access.  There is no specific legal requirement to provide a lock on a commercial 
bin, nor are there any British or European Standards to which any bin locking device must comply. 
Therefore a wide range of locking systems, such as “service” or “cabinet” keys, padlocks, gravity locks, 
lockable straps or combination locks can be found in use.   

The type of locking system selected can depend on the location, size, type and use of the bin, and will 
be influenced by factors such who has supplied or manufactured it, the material from which it is 
constructed, and who is collecting it.  Again these factors will be a matter that should be informed by a 
risk assessment that includes a judgement of the likelihood of a person trying to access the bins, and 
assessment of how robustly the locking device will withstand normal use and attempts to deliberately 
bypass the device. 

Businesses should also monitor their bins (and the surrounding areas) for any signs of attempted 
access or vandalism as part of their ongoing assessment of the risk.   

In deciding how to prevent access to their bins a business will acknowledge that higher levels of 
security will also add to the time and effort required by collection services to empty the bins.   

Bin manufacturers and suppliers have undertaken research to develop a locking system that would be 
effective for all types of commercial bin and container, and which does not have an adverse effect on 
collection crews. Part of this research has concentrated on locks that can be opened from within the 
bin. Whilst these types of locking system are available, it is our understanding that they have not proven 
popular within the industry as they have not been demonstrated to be reliable often due to the robust 
way in which bins are used and handled that leads to damage to the locking mechanism.  

As your specific question relates to what “secure” means I have not set out any detail of the role of the 
collection companies in this response.  WASTE 25 does however give specific details of how they can 
work with the users of bins to manage their safety, reduce the likelihood of access and make routine 
checks to ensure that bins have not been accessed before they are emptied into a vehicle.  

Emphasis should therefore be placed on preventing persons from accessing bins. The approach 
outlined within WISH WASTE 25 - the effective liaison, consultation and communication between those 
who produce and collect waste - is key to preventing people seeking shelter in commercial bins or 
containers from being seriously injured or killed.  

2  

 Yours sincerely 

Head of Waste and Recycling. 

3
Response from Lga (PDF)
Local 4

Government

Association

Andrew Hetherington

Assistant Coroner, City of Sunderland
Civic Centre

Burdon Road

Sunderland

SR2 7DN

22 January 2019

Dear Sir

| write in response to the Regulation 28 Report following your investigation into the death
of Mr James Ryan McLaren. Unfortunately your letter was not received until 4 December
2018 due to email problems. An additional period of time was granted for the LGA to
respond.

Your recommendation to the LGA asked us to raise awareness at national level of the risk
of death or serious injury from access to large commercial or communal bins.

In response to your recommendation an item on the risk of death and injury in large bins
will be included in relevant LGA bulletins and updates to councils. This includes the
weekly email bulletins from the LGA’s Chairman and Chief Executive, and email
newsletters on environment and regulatory issues. These will be circulated in January
and February.

It is helpful to see that the Chartered Institute of Waste Management (CIWM) is engaging
with staff in frontline waste roles, and local authority waste officer networks. This
communication will compliment that of the LGA with senior officers and elected Members.
We will seek further opportunities to raise awareness with councils. If any further material
on this matter is published from the Coroner's Office please let us know so that we can
update our communications.
Yours faithfully

_

H lnAnRee

Hilary Tanner
Adviser, Local Government Association

18 Smith Square, London, SW1P 3HZ T 020 7664 3000 F 020 7664 3030 E info @tocal.gav.uk www.local.gov.uk
Chief Executive: Mark Lloyd

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