Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0026, written 29 Jan 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jan 2021 |
|---|---|
| Reference | 2021-0026 |
| Deceased | Allan Gunnell |
| Coroner | Lydia Brown |
| Coroner area | West London |
| Category | Accident at Work and Health and Safety related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA Tel: 0208 753 6800 Email: hfandhounslowcoroners@lbhf.gov.uk Date: 29 January 2021 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Marble Ideas Limited Unit 1, Station Approach Station Road Langley Berkshire, UK SL3 6DB CORONER I am Mrs. Lydia Brown Area Coroner for West London 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 1st September 2020 I commenced an investigation into the death of Allan David GUNNELL. The investigation concluded at the end of the inquest . The conclusion of the inquest was that Mr Gunnell died from industrial disease as a result of exposure to silica dust in the workplace. The cause of death was 1a Progression of severe pulmonary fibrosis due to silicosis 1b 1c II Chronic Obstructive Pulmonary Disease; Subsegmental pulmonary emboli; pulmonary bilateral upper zone infection CIRCUMSTANCES OF THE DEATH Mr Gunnell was under the care of Interstitial Lung Diseases clinic at Hammersmith Hospital. 1 2 3 4 He had an in-life diagnosis of severe pulmonary fibrosis due to silicosis and the disease progressed to claim his life on 24th August 2020. Prior to his death he had been employed by your company and probably exposed to silica dust in the workplace. 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. – 5 Evidence was requested but not received in relation to the occupational health checks that are carried out by your company, given the hazardous substances and high risk working practises that your employees are exposed to. The Health and Safety executive have published G404 which deals with the requirements placed upon employers who work with respirable crystalline silica (RCS) and there was no evidence before the court that you are working in compliance with this document, and advising your employees of the risks and carrying out the health surveillance required. This therefore potentially puts them at greater risk of developing the disease and not receiving timely health care. I therefore require you to consider the current arrangements in place to protect your employees an whether these are sufficient and in accordance with HSE guidelines and COSHH Regulations 2002. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you Marble Ideas Limited 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 29 March 2021. I, the coroner, may extend the period. 7 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons . I have also sent it to the Health and Safety Executive who may find it useful or of interest. 8 9 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. 29 January 2021 Signature Lydia Brown Area Coroner for West London
1 response 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.
MARBLE IDEAS LIMITED MARBLE ¢ QUARTZSTONE ¢ GRANITE ° LIMESTONE ¢ SLATE * YORK * PORTLAND Unit 1, Station Approach, Station Road, Langley, Berkshire SL3 6DB Tel: 01753 544644 Email: info@marbleideas.co.uk Fax: 01753 549449 www.marbleideas.co.uk Lydia Brown — Area Coroner For West London Coroner's Office West London Coroner Service 25 Bagleys Lane Fulham London SW6 2QA 11% February 2021 Dear Mrs Brown, Death of Allan David Gunnell cet: i) Please find attached information that was sent through the post to you on the 7!" December 2020. Due to a clerical oversight and COVID lockdowns the member of Staff in at the time did not see on your email not to send letters by post, so this we assume is why you never received it. We reviewed our Company Health & Safety Policies in December 2016 using various external monitoring Companies. We implemented a higher level of Health & Safety Procedures and we have followed these upgraded procedures since. An External Yearly Audit is completed by our Safety Consultants, Direct Safety Solutions Ltd and the working practices and environment has not changed, so we are able to keep this high level of safety. We dispute the evidence in your report that states Marble Ideas Limited are not working in Compliance with requirements placed on employers who work with RCS. We at Marble Ideas Ltd are very aware of the risk RCS and as such have rigorous policies and safety procedures in place to protect our employees, in line with the HSE guidelines and COSHH Regulations 2002. Please find attached paperwork for Allan David Gunnell and details below of what we are sending. 4. Health Surveillance Record and Health Surveillance Information. 2. Completed Employee Health Questionnaire. 3. Qualitative Face Fit Test Record. Your ideas turned to Stone Camnanw Revistration No. 2710610 VAT Registration No. GB 579 3790 78 4. Copy of our COSHH Assessment Form for Respirable Silica Dust. 5. Air Monitoring Sample Analysis Report. 6. All stone slab cutting is carried out on a Water Fed Automatic Bridge Saw or a Waterjet Machine. All bowl cut outs are carried out on a fully automatic CNC Water Fed Machine. All hob cut outs are cut on the Waterjet Machine. Air tools with water bottle dust suppression are used for finishing polished edges. All automatic machinery is water fed and used in the stone processing operations at Marble Ideas Ltd. We attached photographs for your information. We were very sorry to hear of Allan’s death but as a company we have implemented all procedures that will protect the safety of our Employees. If you require any other information, please do not hesitate to contact us. Yours sincerely Managing Director.
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