Prevention of Future Deaths reports · 2021
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 report | 5 Oct 2021 |
|---|---|
| Reference | 2021-0331 |
| Deceased | Aaron Fretwell |
| Coroner | Kevin McLoughlin |
| Coroner area | West Yorkshire (East) |
| Category | Product 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.
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
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 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
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.