Prevention of Future Deaths reports · 2019

Christopher Barnes

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 report20 May 2019
Reference2019-0164
DeceasedChristopher Barnes
CoronerKaty Skerrett
Coroner areaGloucestershire
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

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.

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

Responses

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.

Response from Senior Traffic Commissioner for Great Britain (PDF)
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.
Response from Rha (PDF)
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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