Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0164, written 20 May 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 May 2019 |
|---|---|
| Reference | 2019-0164 |
| Deceased | Christopher Barnes |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
H M Senior Coroner for Gloucestershire Mss Katy Skerrett 1 CORONER REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 7 THIS REPORT IS BEING SENT TO (i) | Senior Traffic Commissioner, The Driver Vehicle Standards Agency, Officer of the Traffic Commissioner, Eastbrook, Shaftsbury Road, Cambridge, CB2 8BF (ii) Mr R Burnett, Chief Executive Officer of The Road Haulage Association, Roadway House, Bretton Way, Bretton, Peterborough, PE3 8DD. | am Katy Skerrett, Senior Coroner for Gloucestershire. CORONER’S LEGAL POWERS | 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 the 26" April 2018 | opened an inquest into the death of Christopher George Barnes. The investigation concluded at the end of the Jury inquest on the gt May 2019. The conclusion of the Jury was a short form conclusion of Accidental Death. The medical cause of death was 1A traumatic intra-cranial haemorrhage, 1B Fall from the load on the bed of the lorry. CIRCUMSTANCES OF THE DEATH Mr Barnes was a 69 year old lorry driver employed by a haulage contractor. On the 23" April 2018 he was delivering doors in his curtained side HGV to a company in Fairford. Employees of this company unloaded the HGV. During this process Mr Barnes climbed up onto the bed of the lorry. He then climbed up onto the palletised load. Whilst attempting to untangle the straps which were used to secure the load he took a step back and fell from the lorry impacting with the concrete floor below. He fell approximately 2.3 metres. He was initially unconscious and was transferred by air ambulance to the regional specialist unit. CT investigations demonstrated that he had sustained significant head injuries. He underwent operative intervention. Post operatively his condition steadily deteriorated. He passed away as a result of his injuries at 22.05 hours on the 24" April 2018. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. Whilst the haulage company and the destination company involved in this incident have addressed all the health and safety concerns surrounding this area of practice, 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. — Whether consignees and consigners and their employees have sufficient understanding of the hazards and risks associated with working at height on a vehicle or vehicle trailer, and whether they ensure an appropriate level of safety and have in place sufficient control measures to satisfy their legal obligations. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | coroner@gloucestershire.gov.uk 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 4pm 15" July 2049. |, 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 | am also under a duty to send the Chief Coroner a copy of your response. ‘) eee (2) Devereux Developments Ltd, BLM - Law, FAO Ms Udale, Princes Exchange, 2 Princes Square, Leeds, LS1 4HY (3) Cotswold Doors Ltd DAC Beachcroft, EES »=Portwall Place, Portwall Lane, Bristol BS1 9HS. (4) EEE v1 inspector of Health and Safety, Field Operations Division, Health and Safety Executive, 19 Ridgeway, Quinton Business Park, Birmingham B32 1AL 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 20 2019 Signature Ms K Skerrett Senior Coroner for Gloucestershire Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3D) Tel 01452 305661 | coroner@gloucestershire.gov.uk
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.
aes Senior Traffic Commissioner _ tatfic commissioner T 01223 531028 . . Corporate Office, www.gov.uk/traffic-commissioners for Great Britain Eastbrook, Shaftesbury Road, Cambridge, CB2 8BF Ms K Skerrett H M Senior Coroner for Gloucestershire Gloucestershire Coroner's Court Corinium Avenue Barnwood Gloucester GL4 3DJ 24 May 2019 Dee He Sherot, Re: Mr Christopher George Barnes deceased Regulation 28 Report To Prevent Future Deaths Further to the Regulation 28 Report, following your inquiry into the circumstances surrounding the sad death of Mr Christopher George Barnes, you have suggested that | may have power to prevent future recurrence of the circumstances which led to this tragic loss. As you are aware, the traffic commissioners for Great Britain (TCs) are independent regulators for the heavy goods vehicle (HGV) and public service vehicle (PSV) industries and their professional drivers. We are non-departmental tribunals, sponsored by the Department for Transport (DfT). We act as licensing bodies, issuing operator's licences to the above transport businesses and may take regulatory action against those licence holders, where the requirements of the operator’s licence have not been met. From your report | can infer that the operator in question holds a goods vehicle operator's licence. The requirements for that licence include section 13C of The Goods Vehicle (Licensing of Operators) Act 1995. Section 13C(3) requires only that there be satisfactory arrangements for securing that vehicles used under the licence are not overloaded. Your report at item 4 refers to circumstances where Mr Barnes was involved in the unloading of a vehicle. Mr Barnes climbed onto the palletised load and, whilst attempting to untangle the straps which were used to secure the load, he took a step back and fell from the load on the vehicle. This would appear unconnected with the specific terms of the operator’s licence. As you will be aware, the duties to establish safe systems of work are set out in The Management of Health and Safety at Work Regulations 1999 and The Work at Height Regulations 2005 and by reference to general duties under the Health and Safety at Work etc. Act 1974. Traffic commissioners are not provided with investigative powers or resources. However, a conviction for breaches of the above duties might be relevant to the consideration of an operator's ability to hold an operator’s licence. | regret that | do not have formal powers in the way suggested in your Report as responsibility for enforcing that legislation lies with the Health and Safety Executive. | note that HM inspector J has been copied into the notice. You will no doubt already have been advised of the relevant guidance provided by the Executive of the risks from falls from vehicles, to be found as follows: http:/www.hse.gov.uk/workplacetransport. | am advised that HSE is currently reviewing the approach to vehicle load security. HSE’s Head of Transport Sector, is EEE who is based at 19 Ridgeway, 9 Quinton Business Park, Quinton, Birmingham, B32 1AL It is true that traffic commissioners seek to work with other agencies to ensure that shared concerns regarding the safe operation of vehicles are more widely communicated. Through contacts such as the Vehicle Safety Compliance Forum, chaired by DfT, we continue to liaise with HSE. The next meeting is on 5 June; | will ask my colleague EEN who represents traffic commissioners at that meeting and is commissioner for the traffic area in which your coronial district lies, to raise your concerns and to explore how that guidance might be drawn to the attention of operators more widely. | envisage that is also your purpose in seeking the involvement of The Road Haulage Association. If | have misunderstood the intent of your report, then | would be happy to discuss the issues in more detail with you. Yo Pbacl las Richard Turfitt Senior Traffic Commissioner for Great Britain a |e: Commissioner for the West of England.
The Road Haulage Association RHA Mr Squibbs Gloucester Coroners Court Corinium Avenue Gloucester GL4 3DG 13th June 2019 Dear Mr Squibbs I write further to your recent correspondence enclosing the Regulation 28 letter seeking to prevent future deaths regarding the circumstances surrounding the death of Mr Christopher George Barnes. We at the RHA are a trade association who have strong links with the industry and do represent a significant proportion of the industry, however, as a trade association we do not have a specific mandate with which we can draft or distribute policy documents regarding a members Health and Safety at Work Act obligations. We are however very keen to be of assistance in any way that we feel we can and would be more than happy to listen to ways in which the Coroner may propose that we could assist. Furthermore, we suggest that the most appropriate organisation to whom the Coroner could write with such a request is the Health and Safety Executive (HSE). The HSE have a team who we understand deal specifically with transport and large vehicle fleet operators and as such we believe that they would be interested in and, in order for it to be effective, should be involved with the drafting of any health and safety policies, advice or guidance going forward. The RHA is itself currently engaged with the HSE in drafting guidance with regard to the use of tail-lifts on behalf of the RHA, its members and other trade associations. This is however a costly and very time-consuming exercise (we are currently 3 years into this project) and further work is not something that we can do lightly or easily which may use a disproportionate amount of our members funds. In those circumstances we suggest that the Coroner contact the HSE and ask them to respond to such a request and once that response has been received it may well be that the HSE can engage with the RHA to assist in the drafting of the guidance. It is much harder for us to lead on such a project on our own as we do not have the internal health and safety expertise to carry out such a process. Perhaps a more straightforward activity that we can do is make our members aware of this particular tragic case and of the circumstances surrounding it aid by that way remind them of their obligations to ensure the health and safety of their workforce. In order to achieve this objective however we would need far more detail with regard to the circumstances of the case than are contained within the Regulation 28 request. If we have that information, we can communicate to our 7,000 members via our weekly email as well as our news app and monthly magazine. We also have a website which we would use in this case. Additionally, we could also send a press-release to the industry trade magazines reinforcing the safety message, although we do not have control of those publications and the editors may choose to include or not ir clude the information we provide. We look forwari to hearing from you with any suggestions of how we can help or further information should you wish for us to help publicise the circumstances of this particular tragedy. Yours sincerely I Richard Burnett Chief Executive Road Haulage Association Ltd www.rha.uk.net 22 Greencoat Place, Westminster, London, SW1P 1PR Tel: 020 7630 2121 Email: headofficePrha.uk.net a Registered in England No: 39188
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