Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0439, written 17 Dec 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2019 |
|---|---|
| Reference | 2019-0439 |
| Deceased | Eugeniusz Malek |
| Coroner | Fiona Malek |
| Coroner area | London Inner (West) |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. 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:
Inspector for Health and Safety Executive,
Policy Support Construction
1
CORONER
I am Dr Fiona J Wilcox, HM Senior Coroner, for the Coroner Area of Inner West London
2
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.
3
INVESTIGATION and INQUEST
On the 22th and 23th October 2019, evidence was heard touching the death of
Eugeniusz MALEK. On Saturday 23rd June 2018, Mr Malek was part of a team of
plasterers renovating a house. He fell from a ladder sustaining fatal injuries. He was 50
years old at the time of his death. The jury made the following findings:
Medical Cause of Death
I (a) exsanguination
(b) Transected Right Femoral Artery
(c) Penetrating Injury to Right Groin
II Alcohol Intoxication
How, when, where Mr Malek came by his death:
On 23rd June 2018, at
Mr Eugeniusz Malek fell from a ladder
onto a scaffolding pole resulting in the injuries stated above. He was pronounced dead
at 09:40. On the balance of probabilities the deceased’s alcohol levels contributed to his
death.
Conclusion of the Jury as to the death:
Mr Eugeniusz Malek died as a result of an accident.
4
Extensive evidence was taken in court. In summary, of relevance to this report:
The pole on which Mr Malek landed was uncapped and therefore sharp edged and more
likely to inflict the injuries sustained. There is no current regulation that uncapped
scaffolding poles in areas where a person may fall, walk into, or trip over them should be
capped. Some building sites voluntarily cap such poles, or otherwise pad them. Caps
are relatively cheap and easily available.
5
Concerns of the Coroner:
1. That ends of scaffolding poles sited in areas where workers may fall, trip or
collide with them should be capped.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you
[AND/OR your organisation] have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report. 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons :
Levenes Solicitors.
By email: j
,
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.
9
17th December 2019
Professor Fiona J Wilcox
HM Senior Coroner Inner West London
Westminster Coroner’s Court
65, Horseferry Road
London
SW1P 2ED
Honorary Professor QMUL School of Medicine and Dentistry
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