Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0104, written 20 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2019 |
|---|---|
| Reference | 2019-0104 |
| Deceased | Christopher Bevan |
| Coroner | Tim Holloway |
| Coroner area | Blackpool & Fylde |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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 THIS REPORT IS BEING SENT TO: iy CORONER I am Tim Holloway Assistant Coroner for Blackpool & Fylde 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 06/09/2018 I commenced an investigation into the death of Christopher BEVAN. The investigation concluded at the end of the inquest held on 12'-14" March 2019. The conclusion of the inquest was that the Deceased died as a consequence of an accident and that the medical cause of death was: 1(a) Diffuse brain swelling (operated) 1(b) Blunt head trauma with skull fractures CIRCUMSTANCES OF THE DEATH The circumstances of the death, as determined by the jury, were that on 14" August 2018 between 1500hrs and 1540hrs TE Deceased was last seen undertaking work to the garage roof whilst on a ladder and that he fell and sustained head injuries. The date of death was 15" August 2018 at 1900hrs at Royal Preston Hospital. The jury’s conclusion as to death was “Accident”. 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) That ladders may be used in the course of your work (a) in circumstances in which their use may present a risk to life and/or (b) in a manner in which their use may present a risk to life. The Court received evidence to the effect that the ladders in use at the time of the fatal accident on 14 August 2018 were used on a surface which may have been slippery, that they were not footed during use, that they were not secured at the top save to the extent that they were supported by the blockwork and/or by recently laid coping stones of a facing wall above the door opening of the garage and that they may have been used by the Deceased, with whom you had been working, in a manner which involved him assuming an awkward position in order to carry out work. The concern therefore arises that you may use or those with whom you may work may use ladders in circumstances or in a manner which present a risk to you, to them and/or to others. ACTION SHOULD BE TAKEN t | | | in my opinion action should be taken to prevent future deaths and | believe you PY 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 15'» May 2019. 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 thave sent a copy of my report to the Chief Coroner and to the following Interested Person iy tam 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. 20/03/2019 Signature Tim Holloway Assistant Coroner Blackpool & Fylde
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT Is BENG sent To: [i BLACKPOOL CORONER Iam Tim Holloway Assistant Coroner for Blackpool & Fylde 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 06/09/2018 I commenced an investigation into the death of Christopher BEVAN. The investigation concluded at the end of the inquest held on 12-14" March 2019. The conclusion of the inquest was that the Deceased died as a consequence of an accident and that the medical cause of death was: 1(a) Diffuse brain swelling (operated) 1(b) Blunt head trauma with skull fractures CIRCUMSTANCES OF THE DEATH The circumstances of the death, as determined by the jury, were that on 14" August 2018 between 1500hrs and 1540hrs at a Deceased was last seen undertaking work to the garage roof whilst on a ladder and that he fell and sustained head injuries. The date of death was 15" August 2018 at 1900hrs at Royal Preston Hospital. The jury’s conclusion as to death was “Accident”. 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) That the coping stones on top of the facing blockwork of the garage at your premises may not have been checked subsequent to the fatal accident on 14" August 2018 to ensure that they are secure for reasons of safety and not liable to fall. Whereas the Court received differing evidence as to the weight of each coping stone there is an apparent risk that, should any one of them fall, death may result. My officer has sought to contact you by telephone on my behalf to enquire as to whether such checks have been made but, unfortunately, has been unable to speak to you. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe vo TE 2. 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 15" May 2019. 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: tam 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. 20/03/2019 Signature 7 Tim Holloway Assistant Coroner Blackpool & Fylde
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