Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0268, written 11 Aug 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Aug 2021 |
|---|---|
| Reference | 2021-0268 |
| Deceased | Adam Forrester |
| Coroner | Margaret Jones |
| Coroner area | Stoke-on-Trent and North Staffordshire Coroner’s Court |
| Category | Other related deaths · Alcohol, drug and medication 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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Dr Dr. (WISH Secretary) Inspector of Health and Safety HSE. Redgrave Court, Merton Road, Bootle, Merseyside. L20 7HS 1 CORONER I am Margaret J Jones HM Assistant Coroner for Stoke-on-Trent & North Staffordshire Coroner's Court 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 14/11/2017 I commenced an investigation into the death of Adam Albert John Forrester, aged 30 years. The investigation concluded at the end of the inquest on 28th July 2021. . The cause of death was 1a. Multiple injuries. 2. Alcohol intoxication and cocaine abuse with borderline cardiomegaly and atrial fibrillation. CIRCUMSTANCES OF THE DEATH The deceased had been out drinking in Hanley during the night of the 11/12th September 2017. He was known to have put his jacket into a commercial waste bin prior to visiting a club. He was last seen leaving a night club at 03..26 hours on the 12th September 2017. At 14.39 hours that day he was found dead in the top shed at Browns & Son Recycling, Sneyd Hill Stoke on Trent. Browns had collected waste bins from the vicinity of the night club in the early hours of that morning. The deceased injuries were compatible with being caused by compaction in a bin lorry or other vehicle with a compaction mechanism. There was no evidence as to which vehicle had transported the decease to the recycling plant. CORONER’S CONCERNS 4 5 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. – (1)The bin waggon had collected bins during the hours of darkness in apparently poor weather conditions and from an area vulnerable to vagrants. The vehicle was single crewed. (2)The WISH document, Effective Proactive Monitoring in Waste and Recycling Collection Activities document contains a checklist on page 5 of 8 and a section headed Public Safety at points numbered 20- 22. This section makes no mention of kicking bins or checking inside for persons. This is dealt with in the WISH Guidance Document –managing Access to Large Waste and Recycling Bins but not in the supervision advice document. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you HSE and WISH 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, namely by 07/10/2021. 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: The family of Mr Forrester Browns Recycling via Knights Solicitors Unitas Stoke on Trent City Council I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 11/08/2021 Signature Margaret J Jones HM Assistant Coroner Stoke-on-Trent & North Staffordshire Coroner's Court
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.
Health and Safety Executive HM Principal Inspector of Health and Safety Waste and Recycling Sector Priestley House Priestley Road Basingstoke HANTS RG24 9NW HM Coroner for Stoke-on-Trent and North Staffordshire HM Coroner’s Court & Chambers Stoke Town Hall Kingsway Stoke-on-Trent ST4 1HH FAO Mrs Margaret Jones, Assistant Coroner 29th September 2021 Inquest touching on the death of ADAM FORRESTER Response to Regulation 28 report on behalf of the Health and Safety Executive Dear Mrs Jones I refer to your report of 11th August 2021 which has been passed to me for response as head of HSE’s Waste and Recycling sector team. I have also consulted the Waste Industry Safety and Health forum (WISH) steering group who have many years of experience in the industry to clarify some of the issues. We have worked jointly to amend the guidance, ensure that it is fit for purpose and is as clear as it can be as to the risks and potential control measures. To save duplication, HSE has agreed with WISH that this letter should be regarded as a joint, composite response on behalf of both organisations. I trust this is acceptable. The issue of people sleeping in bins has exercised HSE and the waste and recycling industry for many years. You mention the checklist on page 5 of WISH document ‘Effective Proactive Monitoring in Waste and Recycling Collection Activities’ (INFO 03), in particular, that it makes no mention of kicking bins or checking inside for persons. It is important to distinguish between domestic and commercial type bins. The latter tend to be larger, with four wheels rather than two. They can also be found in communal locations (flats, community centres, schools, churches and ‘bring site’ locations for example). Because these are larger, they tend to be more attractive as a place to sleep. Their safe use is considered in WASTE 25 (Managing access to large waste and recycling bins). As you note, there are various WISH documents which identify good practice to minimise the risks of both sleeping in bins and around bins e.g., under waste such as cardboard. (In the latter case, the risk tends to relate more to being run over by collection vehicles). These risks should be captured in the route risk assessments which waste and recycling contractors are obliged to carry out. Areas known to attract rough sleepers should be identified and extra steps identified to ensure operatives are vigilant for people sleeping in or around bins. On the other hand, people sleeping in standard two wheeled domestic waste (wheelie) bins has been much less of an issue. They are typically too small and filled with contents that are too unpleasant for them to be attractive for sleeping in (even when intoxicated). A person in such a bin would also be very likely to be detected when an operative attempted to move the bin for emptying (the very significant additional weight would almost certainly prompt them to check what was in the bin). There is no conclusive evidence of such bins ever being involved in an accidental death ‘body in the bin’ event. HSE sends to think of risk control measures in terms of a hierarchy – eliminating or reducing it be way of design is at the top, whilst relying on PPE or people following procedures (often in less-than-ideal circumstances) is at the bottom. With this in mind, the best way to prevent further accidents arising from sleeping in or around bins is this for the bin owners (those in control of the premises or undertaking) to take all reasonable steps to keep people out of and away from the bins e.g., by keeping them in locked enclosures or locking the individual bins. This is reflected in WASTE 25. It is the view of both HSE and WISH that kicking bins is weak control measure for various reasons, in particular, because it will not rouse a heavily intoxicated person. Having reviewed the guidance, we are content that the existing material and control measures are broadly sufficient and proportionate to the risk. However, we recognise the wording of WISH INFO 3 could be clearer – so we have drafted some modified text at line 13 on page 5 of INFO13 and with the addition of line 21 on page 6: “Crew check all large, four wheeled bins” (to distinguish from the smaller two wheeled domestic types). I hope this addresses your concerns. Yours faithfully HM Principal Inspector of Health and Safety Chair, Waste and Recycling Health and Safety forum (WISH) 2
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