Prevention of Future Deaths reports · 2021

Aaron Fretwell

Regulation 28 report to prevent future deaths, reference 2021-0331, written 5 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report5 Oct 2021
Reference2021-0331
DeceasedAaron Fretwell
CoronerKevin McLoughlin
Coroner areaWest Yorkshire (East)
CategoryProduct related deaths · Other related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

ANNEX A 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

Bailey Trailers Limited 

1 

CORONER 

I am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East). 

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 5 October 2021, I commenced an investigation into the death of Aaron Darie James 
Fretwell, aged 19. The investigation concluded at the end of the Inquest on Friday 1 
October. The conclusion of the Inquest was ‘Accidental Death’, with the following 
medical cause of death: 

1a) Hypoxic Cerebral Encephalopathy 
1b) Cerebellar Herniation 
2) Lung Contusion
CIRCUMSTANCES OF THE DEATH 

4 

On 2 February 2021, Aaron Darie James Fretwell was working on the family far. In the 
curse of replacing a worn ring on an agricultural trailer, he raised the trailer body and 
disconnected the hydraulic services. Whilst working under the trailer body, it descended, 
tapping him against the chassis, causing him to sustain crush injuries from which he 
died on 3 February 2021. 

5 

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.  – 

1. No propping device was fitted to the trailer, which is understood to have been

manufactured by Bailey Trailers Ltd in about 2002.

2. No warning signs were affixed to the trailer directing that the trailer body should

be propped before anyone worked underneath it.

3. Trailers manufactured by 2002 should have complied with BS EN 1853: 1999
and/or the supply of machinery (Safety) Regulations 1992 which required a
mechanical support to be installed to facilitate maintenance work to be carried
out safely.

1 

 4.  Evidence taken at the Inquest indicated that many types of agricultural trailers 

were in use without such propping devices or warning signs, which gives rise to 
concern that comparable accidents could occur in the future. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you 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 2nd December 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 Aaron Darie James Fretwell (deceased) 
• 

, Health and Safety Executive 

I have also sent it to who may find it useful or of interest: 

•  National institute of Agricultural Engineers 
•  British Agricultural and Garden Machinery Association 

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 

5th October 2021                        

Kevin McLoughlin 

2

Responses

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.

Response from Bailey Trailers Ltd (PDF)
RESPONSE BY BAILEY TRAILERS LIMITED TO THE REGULATION 28 REPORT TO 
PREVENT FUTURE FOLLOWING THE CONCLUSION OF THE INQUEST INTO THE DEATH 
OF AARON DARIE FRETWELL 

INTRODUCTION 

21st October 2021 

Bailey Trailers Limited (“the Company”) makes this response in respect of a regulation 28 report 
to  prevent  future  deaths  made  on  5  October  2021  by  the  Senior  Coroner  for  West  Yorkshire 
(East), Kevin McLoughlin, following the conclusion of the inquest into the death of Aaron Fretwell 
on 1 October 2021 at Leeds Town Hall. 

In the regulation 28 report the circumstances of the death were stated to be, “On 2 February 2021, 
Aaron Darie James Fretwell was working on the family farm. In the course of replacing a worn 
ring on an agricultural trailer, he raised the trailer body and disconnected the hydraulic services. 
Whilst working under the trailer body, it descended, trapping him against the chassis, causing him 
to  sustain  crush  injuries  from  which  he  died  on  3  February  2021”.    The  trailer  involved  in  the 
accident had been manufactured in approximately 2002 by the Company.  The inquest concluded 
with a short-form conclusion of ‘accidental death’. 

In the regulation 28 report the Senior Coroner stated that many types of agricultural trailers are in 
use  without  propping  devices  or  warning  signs,  which  gives  rise  to  concern  that  comparable 
accidents  could  occur  in  the  future.    In  addition  to  the  Company  and  the  Chief  Coroner,  the 
regulation 28 report was sent to Mr Fretwell’s family, Inspector 
 of the Health and 
Safety Executive, the National Institute of Agricultural Engineers and the British Agricultural and 
Garden Machinery Association. 

THE COMPANY’S RESPONSE 

The  Company  takes  its  health  and  safety  responsibilities  very  seriously,  has  considered  the 
Senior  Coroner’s  concerns  and  is  responding  accordingly.    Firstly,  the  family  who  run  the 
Company were deeply saddened to learn of the tragic accident involving one of their trailers and 
wish to convey their sincere condolences to Mr Fretwell’s family and friends. 

The Company is committed to supplying safe and compliant products to the market and to fulfilling 
its legal obligations under the Supply of Safety (Machinery) Regulations 2008 and the Health and 
Safety at Work Act 1974 (amongst others).  The Company’s fundamental position is, and always 
had been, that all routine maintenance of trailers can and should be carried out with the body of 
the trailer in a lowered position.  Where any work would require the body to be in a raised position, 
the  Company  recommends  that  the  body  be  removed  completely.    This  approach  follows  the 
hierarchy of controls for the management of risk by the taking of preventative measures in order 
of priority.  The Company has designed the tipping trailers in a way which eliminates the need for 
maintenance to be carried out underneath a raised body which in itself would introduce potential 
risks which would need to be managed and reduced by engineering controls, i.e. by use of a prop. 

Notwithstanding that point, the Company can confirm that all of its tipping body models are now 
manufactured with body props as a standard feature as per paragraph 4.7.2 of BS EN 1853:2017 
which states that “a mechanical support hinged to the trailer, in conformity with the requirements 
given in EN ISO 4254-1:2015, 4.11 shall be provided to secure the body in high position during 
maintenance operations”.   

The maximum weight of a tipper body is 4000kg of which approximately half is supported by the 
hinges. The prop therefore needs to be able to support 2000kg. Tests have been carried out on 
the  Company’s  tipping  body  models  which  demonstrated  that  the  prop  can  support  the  entire 
4000kg.  Subsequent  tests  were  carried  out  to  8000kg  and  these  caused  no  deformation  or 
damage to the prop, thereby demonstrating its strength. 

The general safety instructions within the Company’s revised Operation & Maintenance Manual 
for all tipping body trailers now states, “For normal maintenance and repairs it is not necessary to 

127344409.1\691479 

1 

 
 raise the body, the design of the trailer permits normal maintenance activities and adjustments to 
be undertaken without the need to raise the tipping body.  In extraordinary circumstances where 
it may become necessary to raise the body, deploy the [mechanical body] support as described 
below”.    The  Manual  reiterates  the  warning  that  users  should  “never  work  beneath  the  raised 
trailer body unless it is securely propped and supported”, and guidance is also given on how to 
deploy and stow the body support safely.  Relevant safety decals (or signs) continue to be used 
to reinforce this point about not tipping the body unless absolutely necessary in the opinion of the 
user. 

Lastly, the Company has emailed its trade dealers (who sell to end users) to ask that they explain 
to their customers that the Company’s tipping trailers have been designed in a way which does 
not require the trailer to be raised for routine maintenance and adjustments but should they decide 
to do so, a prop has been fitted as a standard safety feature.   

21 October 2021 

127344409.1\691479 

2

Related reports

Other reports by Kevin McLoughlin

See all →

More reports categorised “Product related deaths”

See all →

Track Product related deaths

See every Prevention of Future Deaths report matching Product related deaths, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.