Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0063, written 4 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2020 |
|---|---|
| Reference | 2020-0063 |
| Deceased | Jose Orlando |
| Coroner | Nadia Persaud |
| Coroner area | East London |
| Category | Accident at Work and Health and Safety 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.
East London Coroners MISS N PERSAUD SENIOR CORONER Walthamstow Coroner's Court, Queens Road, Walthamstow, E17 8QP Telephone 020 8496 5000 Email coroners@walthamforest.gov.uk 4" March 2020 REF: 9925 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT 10: J! Tradomi S.L., Camino Viejo, 0, 30890, Puerto Lumbreras, Murcia, Spain Sent via email to: Po CORONER lam Miss N Persaud Senior Coroner for East London CORONER’S LEGAL POWERS 1 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 Following an Inquest which was opened on the 18" January 2019 the investigation concluded on the 3% March 2020. The conclusion of the Inquest was a narrative conclusion: Mr Sanchez-Figueroa died from a traumatic brain injury caused by a fall from the back of his lorry. The absence of secure footing and leveraging contributed to the accident. CIRCUMSTANCES OF THE DEATH Mr Sanchez-Figueroa worked as a long distance lorry driver. He had delivered a load of vegetables to the New Spitalfields Market in Leyton, London on the 17 December 2018. At around 20:00 hours on the 17% December 2018 he was found unconscious near to his lorry with a severe head injury. The circumstances in which he was found indicated a likely fall from the back of his trailer. A metal prop/stay that should have been secured in the back of the trailer was found on the ground with blood staining on it. Investigators from the Metropolitan Police Service and the Health and Safety Executive considered that the mechanism of injury was most likely to have been fall from the back of the lorry in which the stay/prop was likely to have been involved. It was noted during the course of the Inquest that there was no hand hold to assist drivers to enter their trailers. It was further noted that drivers would be responsible for stowaways and may need to check the interior of their trailer. Sadly, Mr Sanchez- Figueroa died from his injury’s at the Royal London Hospital on the 23" December 2018. CORONER’S CONCERNS The MATTERS OF CONCERN DURING THE COURSE OF THE INQUEST are as follows. ~ There appeared to be no hand hold/grab rail to assist drivers in pulling themselves up into the interior of their trailers. The metal prop/stay is not designed to be used for this purpose. As there is nothing purpose built to assist drivers to pull themselves up, it would be very tempting for drivers to use the prop/stay for this purpose. In addition, there were no items within the lorry that would have assisted Mr Sanchez-Figueroa to carry out the checks required from the Border Force Agency. Carbon-dioxide detectors or telescopic mirrors could assist drivers with these checks and none of these items were present within the vehicle. 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. 7 May 2020 |, 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, to the solicitor acting on behalf of the family and to the Health & Safety Executive. | 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. Signature Miss N Persaud Senior Coroner East London
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